Nursing Elites

1. During a funduscopic examination of a school-age child, the nurse notes a brilliant, uniform red reflex in both eyes. The nurse should recognize that this is which?

• A. A normal finding
• B. A sign of a possible visual defect and a need for vision screening
• C. An abnormal finding requiring referral to an ophthalmologist
• D. A sign of small hemorrhages, which usually resolve spontaneously

Correct answer: A

Rationale: A brilliant, uniform red reflex in both eyes is a normal finding, indicating that the retina is healthy and there are no significant obstructions in the visual pathway.

2. Frequent urine tests for specific gravity are required on a 6-month-old infant. What method is the most appropriate way to collect small amounts of urine for these tests?

• A. Apply a urine collection bag to the perineal area.
• B. Tape a small medicine cup inside of the diaper.
• C. Aspirate urine from cotton balls inside the diaper with a syringe without a needle.
• D. Use a syringe without a needle to aspirate urine from a superabsorbent disposable diaper.

Correct answer: C

Rationale: Aspirating urine from cotton balls inside the diaper is a minimally invasive method and effective for collecting small amounts of urine. Using a collection bag can be more cumbersome, and other methods are not as effective for this age.

3. What interventions should be implemented to maintain the skin integrity of a preterm infant born at 30 weeks?

• A. Avoid cleaning the skin
• B. Bathe the infant with sterile water
• C. Cleanse the skin with a gentle alkaline-based soap and water
• D. Thoroughly rinse the skin with plain water after bathing

Correct answer: B

Rationale: The correct intervention to maintain the skin integrity of a preterm infant born at 30 weeks is to bathe the infant with sterile water. Bathing with sterile water or a neutral pH solution is recommended to protect the delicate skin of preterm infants, which is more permeable and prone to damage. Choices A, C, and D are incorrect as avoiding cleaning the skin may lead to hygiene issues, cleansing with alkaline-based soap can be harsh on the delicate skin, and thoroughly rinsing with plain water after bathing may not be as gentle and protective for preterm infants.

4. What test is used to screen for carbohydrate malabsorption?

• A. Stool pH
• B. Urine ketones
• C. C urea breath test
• D. ELISA stool assay

Correct answer: A

Rationale: Stool pH testing is used to screen for carbohydrate malabsorption. A low pH indicates the presence of unabsorbed carbohydrates, which are fermented by bacteria, leading to acidic stool.

5. The nurse is assessing a child's capillary refill time. This can be accomplished by doing what?

• A. Inspect the chest
• B. Auscultate the heart
• C. Palpate the apical pulse
• D. Palpate the nail bed with pressure to produce a slight blanching

Correct answer: D

Rationale: Capillary refill time is assessed by applying pressure to the nail bed and observing how quickly the color returns, indicating peripheral circulation status.

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