Nursing Elites

1. The presence of which pair of factors is a good predictor of a fluid deficit of at least 5% in an infant?

• A. Weight loss and decreased heart rate
• B. Capillary refill of less than 2 seconds and no tears
• C. Increased skin elasticity and sunken anterior fontanel
• D. Dry mucous membranes and generally ill appearance

Correct answer: D

Rationale: Dry mucous membranes and an ill appearance are good indicators of dehydration in infants, often correlating with a fluid deficit of at least 5%. Sunken fontanels and poor skin turgor are also indicative but were not options here.

2. The nurse is providing anticipatory guidance to the parent of a 9-month-old infant during a well-baby visit. Which topic would be most appropriate?

• A. Cautioning about putting the infant in a walker
• B. Advising how to create a toddler-safe home
• C. Instructing on safety procedures during baths
• D. Warning about leaving small objects on the floor

Correct answer: D

Rationale: The correct answer is D because at 9 months, infants become more mobile, increasing the risk of choking hazards from small objects left on the floor. Cautioning about putting the infant in a walker (Choice A) is not as crucial at this age as warning about choking hazards. While advising how to create a toddler-safe home (Choice B) is essential, the most critical concern at 9 months is small objects. Instructing on safety procedures during baths (Choice C) is important but does not address the immediate risk of choking hazards associated with small objects.

3. What is characteristic of a neonate’s vision?

• A. Pupils react to light
• B. Tear glands function
• C. Blink reflex is absent
• D. Ciliary muscles are mature

Correct answer: A

Rationale: The correct answer is A: 'Pupils react to light.' Newborns' pupils do react to light, indicating that the visual pathway is functioning. However, a neonate's vision is still developing, and they can only focus on objects close to their face. Choice B is incorrect because tear glands are functional at birth. Choice C is incorrect because the blink reflex is present in neonates and helps protect their eyes. Choice D is incorrect as neonates' ciliary muscles are not fully developed.

4. The parent of a 2-week-old infant asks the nurse if fluoride supplements are necessary because the infant is exclusively breastfed. What is the nurse's best response?

• A. The infant needs to begin taking them now.
• B. Supplements are not needed if you drink fluoridated water.
• C. The infant may need to begin taking them at age 6 months.
• D. The infant can have infant cereal mixed with fluoridated water instead of supplements.

Correct answer: C

Rationale: Breastfed infants may need fluoride supplements starting at 6 months if they are not receiving fluoride from other sources, such as drinking water.

5. Which dietary information should the nurse include in the teaching plan for a school-age child with chronic renal failure?

• A. High in sodium
• B. Low in Vitamin D
• C. Low in phosphorus
• D. Supplementation of vitamins C, E, K

Correct answer: C

Rationale: A low-phosphorus diet is recommended for children with chronic renal failure to prevent hyperphosphatemia, which can lead to bone disease and other complications. Phosphorus is found in many processed foods and should be limited. Choices A, B, and D are incorrect because high sodium intake can lead to fluid retention and hypertension, while Vitamin D supplementation and vitamins C, E, K are not specifically indicated for dietary recommendations in chronic renal failure.

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