Nursing Elites

1. During a clinical conference with a group of nursing students, the instructor is describing burn classifications. The instructor determines that the teaching has been successful when the group identifies what as characteristic of full-thickness burns?

• A. Skin that is reddened, dry, and slightly swollen
• B. Skin appearing wet with significant pain
• C. Skin with blistering and swelling
• D. Skin that is leathery and dry with some numbness

Correct answer: D

Rationale: Full-thickness burns, also known as third-degree burns, are characterized by a leathery, dry appearance with numbness due to nerve damage. This type of burn extends through all layers of the skin, affecting nerve endings. Choice A describes characteristics of superficial partial-thickness burns, which involve the epidermis and part of the dermis. Choice B describes characteristics of superficial burns, or first-degree burns, which only affect the epidermis. Choice C describes characteristics of superficial to mid-dermal burns, also known as second-degree burns, which involve the epidermis and part of the dermis but do not extend through all skin layers. Therefore, the correct answer is D.

2. After corrective surgery for hypertrophic pyloric stenosis (HPS), what should the nurse teach a parent to do immediately after a feeding to limit vomiting?

• A. Rock the infant.
• B. Place the infant in an infant seat.
• C. Place the infant flat on the right side.
• D. Keep the infant awake with sensory stimulation.

Correct answer: B

Rationale: After corrective surgery for hypertrophic pyloric stenosis (HPS), placing the infant in an infant seat is the correct action to take immediately after feeding to limit vomiting. This position helps keep the head elevated, reducing the risk of vomiting. Rocking the infant (Choice A) may agitate the stomach and increase the likelihood of vomiting. Placing the infant flat on the right side (Choice C) is not recommended as it does not encourage proper digestion and may increase the risk of vomiting. Keeping the infant awake with sensory stimulation (Choice D) does not address the positioning concern related to vomiting in this specific post-operative scenario.

3. When assessing a 2-year-old child with abdominal pain and adequate perfusion, general guidelines include

• A. examining the child in the parent's arms
• B. palpating the painful area of the abdomen first
• C. placing the child supine and palpating the abdomen
• D. separating the child from the parent to ensure a reliable examination

Correct answer: A

Rationale: When assessing a 2-year-old child with abdominal pain and adequate perfusion, it is essential to examine the child in the parent's arms. This approach helps reduce anxiety, provide comfort, and establish trust with the child. Palpating the painful area of the abdomen first (Choice B) may cause discomfort and increase anxiety in the child. Placing the child supine and palpating the abdomen (Choice C) without considering the child's comfort and security may lead to resistance and inaccurate assessment. Separating the child from the parent (Choice D) can exacerbate the child's anxiety and hinder the examination process. Therefore, examining the child in the parent's arms is the most appropriate approach in this scenario.

4. An infant is admitted to the neonatal intensive care unit (NICU) with exstrophy of the bladder. What covering should the nurse use to protect the exposed area?

• A. Loose diaper
• B. Dry gauze dressing
• C. Moist sterile dressing
• D. Petroleum jelly gauze pad

Correct answer: C

Rationale: In cases of exstrophy of the bladder, a moist sterile dressing is the most appropriate choice to protect the exposed bladder tissue. Moist sterile dressings help maintain a clean environment, prevent infection, and promote healing. A loose diaper (Choice A) may not provide adequate protection and may lead to contamination. Dry gauze dressing (Choice B) could adhere to the wound and cause trauma upon removal. Petroleum jelly gauze pad (Choice D) is not ideal as it may not provide the necessary barrier against infection and could potentially cause irritation.

5. After a child has just returned from surgery for a tracheostomy, what is the priority nursing action?

• A. Suctioning the tracheostomy tube
• B. Changing the tracheostomy dressing
• C. Monitoring respiratory status
• D. Ensuring the tracheostomy ties are secure

Correct answer: A

Rationale: The priority nursing action after a child has undergone tracheostomy surgery is to suction the tracheostomy tube. Suctioning is crucial to maintain a clear airway, remove secretions, and prevent potential airway obstruction, which is essential for the child's respiratory function. Changing the tracheostomy dressing, while important for wound care, does not take precedence over airway clearance. Monitoring respiratory status is vital but comes after ensuring airway patency. Ensuring tracheostomy ties are secure is significant for stabilizing the tube but is not as urgent as maintaining a patent airway through suctioning.

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