Nursing Elites

1. A 6-year-old with muscular dystrophy was recently injured falling out of bed at home. What intervention should the nurse suggest to prevent further injury?

• A. Recommend raising the bed's side rails when a caregiver is not present.
• B. Suggest a caregiver be present continuously to prevent falls from bed.
• C. Encourage the use of loose restraints while in bed.
• D. Recommend raising the bed's side rails throughout the day and night.

Correct answer: A

Rationale: In this scenario, the most appropriate intervention to prevent further injury is to raise the bed's side rails when a caregiver is not present. This measure helps in preventing falls without the need for constant supervision. Choice B is not practical as continuous caregiver presence may not always be feasible. Choice C is unsafe as loose restraints can pose a strangulation risk. Choice D does not address the need for intervention when a caregiver is absent, potentially leading to an increased risk of falls.

2. When developing the plan of care for a child with burns requiring fluid replacement therapy, what information would the nurse expect to include?

• A. Administration of colloid initially followed by a crystalloid
• B. Determination of fluid replacement based on the type of burn
• C. Administration of most of the volume during the first 8 hours
• D. Monitoring of hourly urine output to achieve less than 1 mL/kg/hr

Correct answer: C

Rationale: The correct answer is C. In fluid replacement therapy for burns, it is crucial to administer most of the volume during the first 8 hours to prevent shock and maintain perfusion. This rapid administration is essential to stabilize the child's condition. Choices A and B are incorrect because the initial fluid replacement in burns typically involves administering crystalloids, not colloids, and the fluid replacement is generally calculated based on the extent of the burn injury, not the type of burn. Choice D is incorrect as monitoring hourly urine output to achieve less than 1 mL/kg/hr is not recommended in burn patients; instead, urine output should be monitored to achieve 1-2 mL/kg/hr in children to ensure adequate renal perfusion.

3. A nurse is preparing a presentation for a parent group about musculoskeletal injuries. When describing a child's risk for this type of injury, the nurse integrates knowledge that bone growth occurs primarily in which area?

• A. Growth plate.
• B. Epiphysis.
• C. Physis.
• D. Metaphysis.

Correct answer: B

Rationale: The correct answer is B: Epiphysis. Bone growth primarily occurs in the epiphysis, which is the area where growth plates are located. The epiphysis is responsible for longitudinal bone growth. Choice A, 'Growth plate,' is incorrect as it does not specify the exact area where bone growth primarily occurs. Choice C, 'Physis,' refers to the same structure as a growth plate, but the term 'epiphysis' is more specific to bone growth. Choice D, 'Metaphysis,' is incorrect as it is the area of the bone where the epiphysis meets the diaphysis, not the primary site of bone growth.

4. When describing urticaria, what would an instructor include?

• A. It is a type IV hypersensitivity reaction.
• B. Histamine release leads to vasodilation.
• C. Wheals appear first followed by erythema.
• D. The nonpruritic rash blanches with pressure.

Correct answer: B

Rationale: The correct answer is B. Urticaria is a type I hypersensitivity reaction where histamine release leads to vasodilation and the formation of characteristic wheals. Choice A is incorrect as urticaria is associated with type I hypersensitivity, not type IV. Choice C is incorrect because in urticaria, erythema typically appears before the development of wheals. Choice D is incorrect as urticaria is typically pruritic and does not blanch with pressure.

5. A parent calls the clinic because their child has ingested a small amount of household bleach. What should the nurse advise?

• A. Administer activated charcoal
• B. Induce vomiting immediately
• C. Call the poison control center
• D. Take the child to the emergency department

Correct answer: C

Rationale: In the case of a child ingesting household bleach, the primary advice should be to call the poison control center (Choice C). The poison control center can provide specific guidance on how to manage the ingestion, including whether any immediate interventions are necessary. Administering activated charcoal (Choice A) or inducing vomiting immediately (Choice B) can worsen the situation as they are not recommended treatments for bleach ingestion. Taking the child to the emergency department (Choice D) may be necessary depending on the advice given by the poison control center, but the initial step should be to seek guidance from the experts at the poison control center.

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