Nursing Elites

1. The nurse is performing an otoscopic examination on a child. Which are normal findings the nurse should expect? (Select all that apply.)

• A. All below
• B. A well-defined light reflex
• C. A small, round, concave spot near the center of the drum
• D. The tympanic membrane is a nontransparent grayish color

Correct answer: A

Rationale: A well-defined light reflex, a small concave spot, and a grayish, nontransparent tympanic membrane are normal findings during an otoscopic examination in a child.

2. The nurse is caring for an infant who had surgical repair of a tracheoesophageal fistula 24 hours ago. Gastrostomy feedings have not been started. What do nursing actions related to the gastrostomy tube include?

• A. Keep the tube clamped.
• B. Suction the tube as needed.
• C. Leave the tube open to gravity drainage.
• D. Secure the tube with tape.

Correct answer: C

Rationale: Leaving the gastrostomy tube open to gravity drainage prevents the accumulation of air and fluids, reducing the risk of complications such as vomiting or aspiration in the immediate postoperative period. Keeping the tube clamped or suctioning it can lead to pressure buildup, increasing the risk of complications. Securing the tube with tape is important but not the primary action related to the gastrostomy tube in this case.

3. What physiologic state(s) produces the clinical manifestations of nervous system stimulation and excitement, such as overexcitability, nervousness, and tetany?

• A. Metabolic acidosis
• B. Respiratory alkalosis
• C. Metabolic and respiratory acidosis
• D. Metabolic and respiratory alkalosis

Correct answer: D

Rationale: Both metabolic and respiratory alkalosis can cause overexcitability and nervous system stimulation due to a decrease in ionized calcium levels, which can cause symptoms such as tetany and paresthesias. Acidosis typically has the opposite effect, leading to depression of the nervous system.

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. When planning care for a child with a urinary tract infection, the nurse should give priority to which treatment measure?

• A. Provide adequate nutrition to prevent dehydration.
• B. Administer ordered antibiotics on schedule.
• C. Prevent enuresis.
• D. Restrict fluid.

Correct answer: B

Rationale: Administering antibiotics on schedule is crucial in treating a UTI effectively and preventing complications. Antibiotics help to eliminate the infection-causing bacteria from the urinary tract. While maintaining adequate nutrition and hydration are important aspects of care, the priority in a UTI is to target the infection with antibiotics. Preventing enuresis (bedwetting) is not directly related to the treatment of the infection. Fluid restriction is not recommended in the management of a UTI; in fact, encouraging adequate fluid intake helps flush out bacteria from the urinary tract.

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