Nursing Elites

1. The nurse is discussing issues that are important with parents considering a cross-racial adoption. Which statement made by the parents indicates further teaching is needed?

• A. "We will try to preserve the adopted child's racial heritage."
• B. "We are glad we will be getting full medical information when we adopt our child."
• C. "We will make sure to have everyone realize this is our child and a member of the family."
• D. "We understand strangers may make thoughtless comments about our child being different from us."

Correct answer: C

Rationale: The statement about making sure others realize the child is part of the family may indicate a focus on external validation rather than on the child’s needs and identity, suggesting a need for further teaching.

2. The nurse is aware that skin turgor best estimates what?

• A. Perfusion
• B. Adequate hydration
• C. Amount of body fat
• D. Amount of anemia

Correct answer: B

Rationale: Skin turgor is a quick and simple way to assess hydration status. Poor skin turgor can indicate dehydration.

3. A child with pyloric stenosis is having excessive vomiting. The nurse should assess for what potential complication?

• A. Hyperkalemia
• B. Hyperchloremia
• C. Metabolic acidosis
• D. Metabolic alkalosis

Correct answer: D

Rationale: Excessive vomiting in pyloric stenosis leads to the loss of stomach acid (hydrochloric acid), resulting in metabolic alkalosis, not hyperkalemia, hyperchloremia, or metabolic acidosis. Metabolic alkalosis is characterized by a higher pH level in the blood due to the loss of acid and a relative increase in bicarbonate. Hyperkalemia is an elevated level of potassium in the blood and is not directly related to excessive vomiting in pyloric stenosis. Hyperchloremia is an excess of chloride in the blood, which is not typically associated with this condition. Metabolic acidosis is a condition characterized by a lower pH level in the blood, caused by an excess of acid or a loss of bicarbonate, which is not the typical complication seen in pyloric stenosis with excessive vomiting.

4. At an 8-month-old well-baby visit, the parent tells the nurse that her infant falls asleep at night during the last bottle feeding but wakes up when moved to the infant’s crib. What is the most appropriate response for the nurse to make?

• A. You should put your baby to sleep 1 hour earlier without the nighttime feeding but with a pacifier for soothing.
• B. You could place rice cereal in the last bottle feeding of the day to ensure a longer sleep pattern.
• C. You should have your partner give the last bottle of the day and observe whether your infant stays awake for your partner.
• D. You could increase daytime feeding intervals to every 4 hours and put your baby in the crib while the baby is still awake.

Correct answer: D

Rationale: Encouraging the baby to fall asleep in the crib while still awake can help establish healthy sleep habits and reduce night waking.

5. Which nursing action is developmentally appropriate when caring for a hospitalized school-age child?

• A. Providing brochures regarding sexuality
• B. Giving clear instructions about details of treatment
• C. Offering medical equipment to play with prior to a procedure
• D. Using toys for distraction during a painful procedure

Correct answer: C

Rationale: Offering medical equipment to play with prior to a procedure is developmentally appropriate when caring for a hospitalized school-age child. Allowing the child to familiarize themselves with the equipment helps reduce fear and anxiety about the upcoming procedure. Choices A, B, and D are not as appropriate for a school-age child. Providing brochures regarding sexuality is not developmentally appropriate for this age group. Giving clear instructions about treatment details may overwhelm a child of this age. Using toys for distraction during a painful procedure is more suitable for younger children.

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