Nursing Elites

1. What is a non-pharmacological management option for measles?

• A. Tepid sponging
• B. Oral hygiene
• C. Eye care
• D. N/A

Correct answer: A

Rationale: Tepid sponging is a non-pharmacological management option for measles. It helps reduce fever and discomfort by using lukewarm water to gently sponge the body. This method is commonly used to alleviate symptoms associated with measles. Oral hygiene and eye care are important for overall health but do not directly manage measles symptoms like tepid sponging does. Choice D, N/A, is incorrect as there are non-pharmacological management options available for measles.

2. A female child, age 2, is brought to the emergency department after ingesting an unknown number of aspirin tablets about 30 minutes earlier. Her father is blaming the mother for neglecting the child while she was cooking. On entering the examination room, the child is crying and clinging to the mother. Which data should the nurse obtain first?

• A. Heart rate, respiratory rate, and blood pressure
• B. Recent exposure to communicable diseases
• C. Number of immunizations received
• D. Height and weight

Correct answer: A

Rationale: In this scenario, the priority is to assess the child's vital signs first, including heart rate, respiratory rate, and blood pressure. These data will provide critical information on the child's current physiological status and guide further interventions. Option B, recent exposure to communicable diseases, is not the priority in an acute ingestion situation. Option C, number of immunizations received, and option D, height and weight, are important but not as critical as assessing vital signs in this immediate situation.

3. What intervention should the nurse encourage for a postpartum client complaining of perineal pain?

• A. Use of ice packs for the first 24 hours
• B. Application of heat packs immediately
• C. Avoiding the use of peri-bottles
• D. Using tampons to manage lochia

Correct answer: A

Rationale: The correct intervention for perineal pain in a postpartum client is the use of ice packs for the first 24 hours. Ice packs help reduce swelling and discomfort in the perineal area, especially during the initial post-delivery period. Applying heat packs can exacerbate swelling and discomfort. Avoiding peri-bottles may lead to poor perineal hygiene. Using tampons is contraindicated postpartum as it increases the risk of infection.

4. The client is being taught about perineal care postpartum. Which instruction should the client receive?

• A. Use ice packs to reduce swelling for the first 24 hours.
• B. Apply heat packs immediately after birth to reduce pain.
• C. Avoid using a peri-bottle to cleanse the perineum.
• D. Use tampons to absorb lochia discharge.

Correct answer: A

Rationale: The correct instruction for the client postpartum is to use ice packs to reduce swelling for the first 24 hours. This helps alleviate discomfort and promote healing. Applying heat packs immediately after birth is not recommended as they can increase swelling. A peri-bottle is advised for cleansing the perineum, not to be avoided. Tampons should not be used to absorb lochia discharge as they can increase the risk of infection. Therefore, the use of ice packs is the most appropriate and beneficial instruction for perineal care postpartum.

5. Which of the following is a more reliable indicator of perfusion in children than in adults?

• A. Blood pressure
• B. Heart rate
• C. Respiratory rate
• D. Capillary refill

Correct answer: D

Rationale: Capillary refill is a more reliable indicator of perfusion in children than in adults. This is because children have more compliant vessels, making capillary refill a more sensitive indicator of perfusion status in this population. In contrast, while blood pressure, heart rate, and respiratory rate are important indicators, they may not be as reliable in children as capillary refill. Blood pressure can be affected by various factors such as anxiety or pain, heart rate can be influenced by emotions or temperature, and respiratory rate may vary with activity levels. Therefore, capillary refill is preferred in children for a more accurate assessment of perfusion.

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