Nursing Elites

1. The nurse determines that a child's intravenous infusion has infiltrated. The infused solution is a vesicant. What is the most appropriate nursing action?

• A. Stop the infusion and apply ice.
• B. End the infusion and notify the practitioner.
• C. Slow the infusion rate and notify the practitioner.
• D. Discontinue the infusion and apply warm compresses.

Correct answer: B

Rationale: If a vesicant solution infiltrates, stopping the infusion immediately and notifying the practitioner is critical to prevent tissue damage. Cold or warm compresses should only be applied following specific medical advice based on the vesicant involved.

2. Pretending a sheet is a cape to mimic a superhero is characteristic of which childhood phenomenon?

• A. Artificialism
• B. Symbolic functioning
• C. Critical thinking
• D. Dramatic play

Correct answer: B

Rationale: The correct answer is B, symbolic functioning. Symbolic functioning refers to children using objects, actions, or ideas to represent other objects, actions, or ideas. In this scenario, pretending a sheet is a cape to mimic a superhero demonstrates the child's ability to engage in symbolic play. Choice A, artificialism, is incorrect as it refers to the belief that inanimate objects have lifelike qualities. Choice C, critical thinking, does not directly relate to the imaginative play described in the question. Choice D, dramatic play, is close but not as precise as symbolic functioning, which specifically highlights the use of objects to represent something else.

3. Which is a complication that can occur after abdominal surgery if pain is not managed?

• A. Atelectasis
• B. Hypoglycemia
• C. Decrease in heart rate
• D. Increase in cardiac output

Correct answer: A

Rationale: Poorly managed pain after abdominal surgery can lead to complications like atelectasis due to shallow breathing, which may occur if the child avoids deep breaths because of pain.

4. 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.

5. What dietary modification is recommended for a child with cystic fibrosis?

• A. High carbohydrate
• B. Low protein
• C. High calorie
• D. Low fat

Correct answer: C

Rationale: A high-calorie diet is recommended for children with cystic fibrosis due to their increased energy needs and malabsorption issues. Cystic fibrosis affects the pancreas, leading to poor digestion and absorption of nutrients, particularly fats, which requires dietary adjustments to maintain adequate nutrition. High carbohydrate (Choice A) is not the primary focus; the emphasis is on overall calorie intake. Low protein (Choice B) is not recommended as protein intake is essential for growth and development. Low fat (Choice D) is not the best option as fat-soluble vitamin absorption is already compromised in cystic fibrosis, hence fat restriction is not a priority.

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