Nursing Elites

1. What information should be included in the preoperative plan of care for an infant with myelomeningocele?

• A. Positioning the infant supine with a pillow under the buttocks
• B. Covering the sac with saline-soaked nonadhesive gauze
• C. Wrapping the infant snugly in a blanket
• D. Applying a diaper to prevent fecal soiling of the sac

Correct answer: B

Rationale: Covering the sac with saline-soaked nonadhesive gauze is essential in the preoperative care of an infant with myelomeningocele. This practice helps prevent infection and maintains moisture around the sac before surgery, promoting optimal healing outcomes. Positioning the infant supine with a pillow under the buttocks may be uncomfortable and unnecessary. Wrapping the infant snugly in a blanket does not address the specific care needs of the myelomeningocele. Applying a diaper over the sac can increase the risk of infection and should be avoided in this case.

2. A healthcare provider is assessing a child with suspected Kawasaki disease. What clinical manifestation is the healthcare provider likely to observe?

• A. Generalized rash
• B. Peeling skin on the hands and feet
• C. High fever
• D. Low-grade fever

Correct answer: B

Rationale: Peeling skin on the hands and feet is a characteristic clinical manifestation of Kawasaki disease, known as desquamation. This occurs during the convalescent phase of the illness. While Kawasaki disease is associated with a high fever, which is a common early sign, and can also present with other symptoms like conjunctivitis, mucous membrane changes, and lymphadenopathy, the peeling skin on the hands and feet is a classic feature that distinguishes Kawasaki disease from other conditions. Generalized rash is not a specific hallmark of Kawasaki disease, and low-grade fever is not typically associated with this condition. Therefore, the correct answer is B, peeling skin on the hands and feet, which is a key feature of Kawasaki disease.

3. A nurse is caring for an infant with phenylketonuria (PKU). What diet should the nurse anticipate will be ordered by the healthcare provider?

• A. Fat-free
• B. Protein-enriched
• C. Phenylalanine-free
• D. Low-phenylalanine

Correct answer: D

Rationale: A low-phenylalanine diet is necessary for infants with PKU because it helps prevent the accumulation of phenylalanine, which can result in brain damage. Fat-free (Choice A) and protein-enriched (Choice B) diets are not specifically indicated for PKU. While phenylalanine-free (Choice C) may seem logical, complete elimination of phenylalanine is not practical or safe as it is an essential amino acid. Therefore, the correct choice is a low-phenylalanine diet, which restricts phenylalanine intake to a safe level.

4. A 4-year-old child is scheduled for a myringotomy. What should the nurse include in the preoperative teaching?

• A. Explain the procedure in simple terms
• B. Encourage fluid intake
• C. Allow the child to play with medical equipment
• D. Use play therapy to prepare the child

Correct answer: A

Rationale: Explaining the procedure in simple terms is essential preoperative teaching for a 4-year-old child scheduled for a myringotomy. This approach helps the child understand what will happen during the procedure, reducing anxiety and fear. Encouraging fluid intake is a good general health practice but not directly related to preoperative teaching for this procedure. Allowing the child to play with medical equipment may not be safe or appropriate as it can lead to misunderstanding or fear. Using play therapy can be beneficial but explaining the procedure in simple terms is more direct and effective for preoperative teaching in this case.

5. A healthcare provider is assessing a child with suspected pneumonia. What clinical manifestation is the healthcare provider likely to observe?

• A. Cough
• B. Diarrhea
• C. Rash
• D. Vomiting

Correct answer: A

Rationale: When assessing a child with suspected pneumonia, a healthcare provider is likely to observe a cough as a common clinical manifestation. Pneumonia often presents with symptoms such as cough, fever, difficulty breathing, and chest pain. Choice B, diarrhea, is not typically associated with pneumonia. Choice C, rash, is not a common clinical manifestation of pneumonia. Choice D, vomiting, is also not a typical symptom of pneumonia. Therefore, the correct answer is A: Cough.

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