Nursing Elites

1. The nurse is teaching a nursing student about standard precautions. Which statement made by the student indicates a need for further teaching?

• A. I will use precautions when I give an infant oral care
• B. I will use precautions when I change an infant's diaper
• C. I will use precautions when I come in contact with blood and body fluids
• D. I will use precautions when administering oral medications to a school-age child

Correct answer: D

Rationale: Standard precautions are necessary when dealing with blood, body fluids, and potentially infectious materials. They are not required for routine administration of oral medications unless there is a potential exposure risk.

2. The nurse is caring for a very low-birth-weight (VLBW) infant with a peripheral intravenous infusion. What nursing considerations regarding infiltration should be included in planning IV care?

• A. Infiltration is not solely related to the activity level of VLBW infants.
• B. Continuous infusion pumps do not always stop automatically when infiltration occurs.
• C. Hypertonic solutions can cause severe tissue damage if infiltration occurs.
• D. The infusion site should be checked regularly to prevent infiltration-related complications.

Correct answer: C

Rationale: Hypertonic solutions can damage tissues if they leak from the vein due to infiltration. It is crucial to monitor for this complication to prevent severe tissue damage. Infiltration is not solely related to the activity level of VLBW infants; it can occur due to various reasons such as vein condition, catheter placement, and fluid type. Continuous infusion pumps may not always detect infiltration, as they typically alarm for pressure changes but not all infiltration instances. Checking the infusion site regularly, preferably hourly, is essential to prevent complications like tissue damage from extravasations, fluid overload, and dehydration.

3. At what stage can infants raise their heads and gain control of their trunks before walking due to which directional pattern of development?

• A. Cephalocaudal
• B. Anterior to posterior
• C. Proximodistal
• D. Normal growth curve charts

Correct answer: A

Rationale: The correct answer is A: Cephalocaudal. The cephalocaudal pattern of development means that growth and motor control proceed from the head downward through the body. This explains why infants can raise their heads before they can sit and gain control of their trunks before walking. Choices B, C, and D are incorrect. Anterior to posterior refers to development from the front to the back, while proximodistal refers to development from the center of the body outward. Normal growth curve charts are used to track physical growth over time and are not directly related to the directional pattern of development in infants.

4. An infant has been diagnosed with failure to thrive (FTT) classified according to the pathophysiology of defective utilization. The nurse understands that the reason for the FTT is most likely related to what?

• A. Cystic fibrosis
• B. Hyperthyroidism
• C. Congenital infection
• D. Breastfeeding problems

Correct answer: C

Rationale: FTT classified as defective utilization is often related to conditions like congenital infections, which interfere with the body's ability to effectively use nutrients. Conditions like cystic fibrosis and hyperthyroidism can also contribute to FTT but are categorized differently

5. Which disease would require strict isolation of the patient?

• A. Mumps
• B. Chickenpox
• C. Exanthema subitum (roseola)
• D. Erythema infectiosum (fifth disease)

Correct answer: B

Rationale: The correct answer is B: Chickenpox. Chickenpox is highly infectious and is transmitted through direct contact, droplet spread, and contaminated objects. Due to its high communicability, strict isolation of the patient is necessary to prevent the spread of the disease. Mumps is primarily transmitted through direct contact with the infected person's saliva, with peak contagiousness before the onset of swelling. Exanthema subitum (roseola) has an unknown transmission source. Erythema infectiosum (fifth disease) is contagious before the appearance of symptoms. Therefore, these diseases do not require the same level of strict isolation as chickenpox.

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