Nursing Elites

1. An infant is diagnosed with a tracheoesophageal fistula. Which assessment finding should the nurse expect?

• A. Jaundice
• B. Hyperactive bowel sounds
• C. Absence of sucking, vomiting
• D. Coughing, with excessive secretion

Correct answer: D

Rationale: Coughing with excessive secretion is a common sign of tracheoesophageal fistula. In this condition, the connection between the trachea and esophagus allows saliva and food to enter the airways, leading to coughing and excessive secretions. Choice A, jaundice, is not typically associated with tracheoesophageal fistula. Hyperactive bowel sounds (Choice B) are more likely seen in conditions like gastroenteritis. Absence of sucking and vomiting (Choice C) is not a typical finding related to tracheoesophageal fistula.

2. An appropriate method for administering oral medications that are bitter to an infant or small child should be to mix them with which?

• A. Bottle of formula or milk
• B. Any food the child is going to eat
• C. One teaspoon of something sweet-tasting such as jam
• D. Carbonated beverage, which is then poured over crushed ice

Correct answer: C

Rationale: Mixing bitter medication with a small amount of something sweet, like jam, can mask the taste effectively without diluting the medication too much. Mixing with milk or formula is not recommended as the child may refuse future feedings, and carbonated beverages are not suitable for infants.

3. Which actions by the nurse demonstrate clinical reasoning? (Select all that apply.)

• A. All below
• B. Considering alternative actions
• C. Using formal and informal thinking to gather data
• D. Giving deliberate thought to a patient's problem

Correct answer: A

Rationale: Clinical reasoning involves deliberate and thoughtful decision-making, considering alternatives, and using both formal and informal data gathering methods to provide optimum care.

4. The parent of an 8.2-kg (18-lb) 9-month-old infant is borrowing a federally approved car seat from the clinic. The nurse should explain that the safest way to put in the car seat is what?

• A. Front facing in back seat
• B. Rear facing in back seat
• C. Front facing in front seat with air bag on passenger side
• D. Rear facing in front seat if an air bag is on the passenger side

Correct answer: B

Rationale: Infants should be placed rear-facing in the back seat until they are at least 2 years old or exceed the weight/height limit of their car seat for optimal safety.

5. In the newborn, into what muscle is intramuscular vitamin K administered?

• A. Deltoid
• B. Dorsogluteal
• C. Rectus femoris
• D. Vastus lateralis

Correct answer: D

Rationale: In newborns, intramuscular vitamin K is traditionally administered into the vastus lateralis muscle. This site is preferred due to its large muscle mass and accessibility. The dorsogluteal site is not recommended for newborns due to the risk of injury to the sciatic nerve. The deltoid site is also not recommended for newborns. The rectus femoris muscle is not commonly used for intramuscular injections in newborns.

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