Nursing Elites

1. The healthcare provider is preparing to suture a 10-year-old child with a lacerated forehead. Both parents and a 12-year-old sibling are present at the child's bedside. Which instruction best supports family involvement?

• A. While waiting for the healthcare provider, only one visitor may stay with the child.
• B. All of you should leave while the healthcare provider sutures the child's forehead.
• C. It is best if the sibling goes to the waiting room until the suturing is completed.
• D. Please decide who will stay when the healthcare provider begins suturing.

Correct answer: D

Rationale: Involving the family members in deciding who will stay when the healthcare provider begins suturing supports family involvement and helps reduce anxiety for the child. This approach respects the family's dynamics and preferences, promoting a supportive environment during the procedure.

2. The nurse determines that an infant admitted for surgical repair of an inguinal hernia voids a urinary stream from the ventral surface of the penis. What action should the nurse take?

• A. Document the finding
• B. Palpate scrotum for testicular descent
• C. Assess for bladder distension
• D. Auscultate bowel sounds

Correct answer: A

Rationale: The correct action for the nurse to take in this situation is to document the finding. The infant voiding a urinary stream from the ventral surface of the penis suggests hypospadias, a condition where the urethral opening is on the underside of the penis. This finding is crucial information that needs to be documented for further evaluation. Palpating the scrotum for testicular descent, assessing for bladder distension, and auscultating bowel sounds are not appropriate actions based on the presented scenario and do not address the specific concern of the urinary stream location.

3. The healthcare provider is preparing to administer a vaccine to a 5-year-old child. The child is visibly anxious and asks if the shot will hurt. What is the healthcare provider’s best response?

• A. It might hurt a little, but it will be over quickly
• B. It won't hurt at all, don't worry
• C. You're a big kid now, and big kids don't cry
• D. If you don't think about it, it won't hurt

Correct answer: A

Rationale: When a child expresses fear or anxiety about receiving a vaccination, it is essential for the healthcare provider to provide honest and reassuring information. Choice A acknowledges the potential for some discomfort but also reassures the child that it will be over quickly. This response validates the child's feelings while also preparing them for the procedure. Choices B, C, and D either provide false reassurance, dismiss the child's feelings, or suggest avoidance, which are not appropriate responses in this situation.

4. An 8-year-old male client with nephrotic syndrome is receiving salt-poor human albumin IV. Which findings indicate to the nurse that the child is manifesting a therapeutic response?

• A. Decreased urinary output
• B. Decreased periorbital edema
• C. Increased periods of rest
• D. Weight gain of 0.5 kg/day

Correct answer: B

Rationale: In nephrotic syndrome treatment, decreased periorbital edema is a positive therapeutic response as it indicates a reduction in fluid retention. Periorbital edema is a common symptom of nephrotic syndrome due to fluid accumulation, so a decrease in this swelling signifies an improvement in the condition.

5. A 9-week-old infant is scheduled for cleft lip repair. Which information is most important for the nurse to convey to the surgeon before transporting the infant to the surgical suite?

• A. Red blood cell count of 2.3 million/mm³
• B. White blood cell count of 10,000/mm³
• C. Weight gain of 2 pounds since birth
• D. Urine specific gravity is 1.011

Correct answer: A

Rationale: The correct answer is A because a low red blood cell count may indicate anemia, which could pose risks during surgery. Anemia can affect oxygen delivery to tissues, impacting wound healing and overall surgical outcomes. The other options, such as white blood cell count, weight gain, and urine specific gravity, are less critical for immediate surgical considerations. White blood cell count is more related to infection risk postoperatively rather than immediate surgical risk. Weight gain reflects good overall growth but does not impact the immediate surgical situation. Urine specific gravity is more indicative of hydration status rather than immediate surgical risk.

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