Nursing Elites

1. The nurse is performing an oral examination on a preschool child. Which strategies should the nurse use to encourage the child to open the mouth for the examination? (Select all that apply.)

• A. Lightly brush the palate with a cotton swab
• B. Perform the examination in front of a mirror
• C. Let the child examine someone else's mouth first
• D. All of the above

Correct answer: D

Rationale: Using a cotton swab, allowing the child to observe, and demonstrating on someone else are effective ways to encourage a preschooler to open their mouth for examination.

2. The nurse is conducting discharge teaching to an adolescent with a methicillin-resistant Staphylococcus aureus (MRSA) infection. What should the nurse include in the instructions?

• A. Avoid sharing of towels and washcloths
• B. All are applicable
• C. Use bleach when laundering towels and washcloths
• D. Take a daily bath or shower with an antibacterial soap

Correct answer: B

Rationale: Avoiding sharing of towels and washcloths, using bleach when laundering, and taking daily baths with antibacterial soap are critical to prevent the spread of MRSA. Cold water is not effective for laundering in these cases.

3. Which electrolyte imbalance is a common concern in children with severe diarrhea?

• A. Hypernatremia
• B. Hypokalemia
• C. Hypercalcemia
• D. Hypomagnesemia

Correct answer: B

Rationale: Hypokalemia is the correct answer because it is a common concern in children with severe diarrhea. Diarrhea can lead to significant potassium loss, resulting in hypokalemia. Hypernatremia (Choice A) is less common in diarrhea as sodium concentration is usually diluted by the fluid loss. Hypercalcemia (Choice C) is not typically associated with severe diarrhea. Hypomagnesemia (Choice D) can occur but is not as common as hypokalemia in this scenario.

4. Which of the following is the best indicator of a child's nutritional status?

• A. Weight
• B. Height
• C. Head circumference
• D. Mid-upper arm circumference

Correct answer: D

Rationale: Mid-upper arm circumference is a good indicator of muscle mass and fat stores, reflecting a child's nutritional status. It is particularly useful in assessing malnutrition, as it is less affected by fluid retention or dehydration compared to other anthropometric measurements. Weight can fluctuate due to factors like hydration status, making it less reliable as a sole indicator of nutritional status. Height reflects growth but may not directly indicate current nutritional status. Head circumference is more related to brain growth and development rather than overall nutritional status.

5. The apnea monitor alarm sounds on a neonate for the third time during this shift. What is the priority action by the nurse?

• A. Provide tactile stimulation.
• B. Administer 100% oxygen.
• C. Investigate possible causes of a false alarm.
• D. Assess infant for color and presence of respirations.

Correct answer: D

Rationale: The priority action for the nurse when the apnea monitor alarm sounds on a neonate is to assess the infant for color and the presence of respirations. This initial assessment helps determine the infant's respiratory status and the need for immediate intervention. Providing tactile stimulation or administering oxygen should only be done after assessing the infant's respiratory status. Investigating possible causes of a false alarm comes after ensuring the infant's well-being through the initial assessment.

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