Nursing Elites

1. 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.

2. A 5-year-old has patient-controlled analgesia (PCA) for pain management after abdominal surgery. What information does the nurse include in teaching the parents about the PCA?

• A. The child may not be pain-free.
• B. The parents or nurse may push the button for a bolus if needed.
• C. The pump allows for a continuous basal rate to deliver a constant amount of medication for pain control.
• D. Monitoring is required every 1 to 2 hours to assess patient response.

Correct answer: C

Rationale: The correct answer is C because the PCA pump can be programmed to deliver a continuous basal rate of pain medication to maintain pain control. While the goal of PCA is effective pain relief, it does not guarantee a pain-free state. In the case of a 5-year-old child, the parents or nurse can administer boluses if necessary since the child may not fully comprehend using the PCA button. Monitoring every 1 to 2 hours for patient response is adequate and there is no need for monitoring every 15 minutes, as stated in choice D, unless specific circumstances dictate more frequent monitoring.

3. When planning care for a child with a urinary tract infection, the nurse should give priority to which treatment measure?

• A. Provide adequate nutrition to prevent dehydration.
• B. Administer ordered antibiotics on schedule.
• C. Prevent enuresis.
• D. Restrict fluid.

Correct answer: B

Rationale: Administering antibiotics on schedule is crucial in treating a UTI effectively and preventing complications. Antibiotics help to eliminate the infection-causing bacteria from the urinary tract. While maintaining adequate nutrition and hydration are important aspects of care, the priority in a UTI is to target the infection with antibiotics. Preventing enuresis (bedwetting) is not directly related to the treatment of the infection. Fluid restriction is not recommended in the management of a UTI; in fact, encouraging adequate fluid intake helps flush out bacteria from the urinary tract.

4. What is the best age to introduce solid food into an infant’s diet?

• A. 2 to 3 months
• B. 4 to 6 months
• C. When birth weight has tripled
• D. When tooth eruption has started

Correct answer: B

Rationale: The introduction of solid foods is recommended at 4 to 6 months when the infant's digestive system is more developed and ready for solids.

5. The parents of a 2-year-old boy who had a repair of exstrophy of the bladder at birth ask when they can begin toilet training their son. The nurse replies based on what knowledge?

• A. Most boys in the United States can be toilet trained at age 3 years.
• B. Training can begin when he has sufficient bladder capacity.
• C. Additional surgery may be necessary to achieve continence.
• D. They should begin now because he will require additional time.

Correct answer: B

Rationale: Toilet training should begin when the child has sufficient bladder capacity and control, which may be delayed in children who have undergone surgical repairs for conditions like bladder exstrophy. Premature training can lead to frustration and setbacks.

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