Nursing Elites

1. The nurse needs to take the blood pressure of a small child. Of the cuffs available, one is too large and one is too small. The best nursing action is which?

• A. Use the small cuff
• B. Use the large cuff
• C. Use either cuff using the palpation method
• D. Wait to take the blood pressure until a proper cuff can be located

Correct answer: D

Rationale: It is essential to use the correct cuff size for accurate blood pressure readings; if the proper size is not available, it's best to wait until it can be obtained.

2. What play activities should the nurse implement to encourage fluid intake for a child? (Select all that apply.)

• A. Have a tea party.
• B. Use a crazy straw.
• C. Cut gelatin into fun shapes.
• D. All of the above

Correct answer: D

Rationale: Encouraging fluid intake can be fun and engaging through activities like having a tea party, using a crazy

3. A child is admitted with acute glomerulonephritis. What should the nurse expect the urinalysis during this acute phase to show?

• A. Bacteriuria and hematuria
• B. Hematuria and proteinuria
• C. Bacteriuria and increased specific gravity
• D. Proteinuria and decreased specific gravity

Correct answer: B

Rationale: Hematuria (blood in the urine) and proteinuria (protein in the urine) are common findings in acute glomerulonephritis due to inflammation of the glomeruli. Bacteriuria and changes in specific gravity are not as directly associated with this condition.

4. The school nurse suspects a testicular torsion in a young adolescent student. What action should the nurse take?

• A. Place a warm moist pack on the scrotal area.
• B. Instruct the adolescent to lie down and elevate the legs.
• C. Refer the adolescent for immediate medical evaluation.
• D. Suggest that the adolescent wear a scrotum-protecting guard.

Correct answer: C

Rationale: Testicular torsion is a surgical emergency requiring immediate medical evaluation. Applying heat or elevating the legs will not alleviate the torsion, and delaying care can lead to testicular necrosis.

5. Several types of long-term central venous access devices are used. What is a benefit of using an implanted port (e.g., Port-a-Cath)?

• A. You do not need to pierce the skin for access.
• B. It is easy to use for self-administered infusions.
• C. The patient does not need to limit regular physical activity, including swimming.
• D. The catheter cannot dislodge from the port even if the child plays with the port site.

Correct answer: C

Rationale: Implanted ports like the Port-a-Cath are fully implanted under the skin, allowing the child to maintain regular physical activities, including swimming, without the risk of dislodging the catheter. Piercing the skin is still required for access, and self-administration is more complex.

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