Nursing Elites

1. The nurse is preparing to give acetaminophen (Tylenol) to a child who has a fever. What nursing action is appropriate?

• A. Retake the temperature in 15 minutes after giving the Tylenol.
• B. Place a warm blanket on the child so chilling does not occur.
• C. Check to be sure the Tylenol dose does not exceed 15 mg/kg.
• D. Use cold compresses instead of Tylenol to control the fever.

Correct answer: C

Rationale: Ensuring the dose does not exceed 15 mg/kg is critical to avoid overdose and potential liver damage. Retaking the temperature immediately or using cold compresses is not necessary, and placing a warm blanket could exacerbate the fever.

2. What does the American Academy of Pediatrics recommend as the best form of infant nutrition?

• A. Exclusive breastfeeding until 1 year of age
• B. Exclusive breastfeeding until 6 months of age
• C. Commercially prepared infant formula until 1 year of age
• D. Commercially prepared infant formula until 4 to 6 months of age

Correct answer: A

Rationale: The American Academy of Pediatrics advocates for exclusive breastfeeding until 1 year of age as the best form of infant nutrition. Breastfeeding for the first year of life provides optimal nutrition and benefits for the infant. Exclusive breastfeeding until 6 months of age is not in line with the AAP's recommendation for a full year. While commercially prepared infant formula is an alternative if breastfeeding is not possible, it is not the preferred choice according to AAP guidelines. The recommendation for commercial infant formula until 1 year of age is not in line with the AAP's stance on the benefits of extended breastfeeding.

3. The nurse is preparing to complete documentation on a patient's chart. Which should be included in documentation of nursing care? (Select all that apply.)

• A. Reassessments
• B. Nursing care provided
• C. Initial assessments
• D. All of the above

Correct answer: D

Rationale: Proper documentation includes reassessments, initial assessments, care provided, and the patient's response, but incident reports are typically documented separately.

4. A school-age child with cancer is being prepared for a procedure. The child says, “I have had one of these before. They hurt.” The nurse bases her response on what knowledge related to pain in this patient?

• A. Often misrepresent experiencing pain
• B. Tolerate pain better than adults
• C. Become accustomed to painful procedures
• D. Commonly experience treatment-related moderate to severe pain when they have cancer

Correct answer: D

Rationale: The correct answer is D. Pain is frequently reported by children with cancer, with around 84% experiencing it. Most children report moderate to severe pain, with about half finding it highly distressing. There is no evidence to suggest that children often misrepresent their pain experiences. Pain tolerance is not solely based on age but is a complex phenomenon. Children do not become accustomed to painful procedures, as each experience of pain is unique.

5. The nurse is assessing a child's capillary refill time. This can be accomplished by doing what?

• A. Inspect the chest
• B. Auscultate the heart
• C. Palpate the apical pulse
• D. Palpate the nail bed with pressure to produce a slight blanching

Correct answer: D

Rationale: Capillary refill time is assessed by applying pressure to the nail bed and observing how quickly the color returns, indicating peripheral circulation status.

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