Nursing Elites

1. What is a priority intervention for an infant with a temporary colostomy for Hirschsprung disease?

• A. Teaching how to irrigate the colostomy
• B. Protecting the skin around the colostomy
• C. Discussing the implications of a colostomy during puberty
• D. Using simple, straightforward language to prepare the child

Correct answer: B

Rationale: Protecting the skin around the colostomy is crucial to prevent irritation and infection, which are common complications in infants with colostomies. Teaching and discussing long-term implications are important but secondary to immediate skin care needs.

2. Latex allergy is suspected in a child with spina bifida. What are appropriate nursing interventions to include in care of this patient?

• A. Avoid using any latex product.
• B. Use only non-allergenic latex products.
• C. Teach the family about long-term management of asthma.
• D. Administer medication for long-term desensitization.

Correct answer: A

Rationale: The correct answer is A: 'Avoid using any latex product.' In the case of a suspected latex allergy, it is crucial to prevent exposure to latex products to avoid allergic reactions. Choice B is incorrect because there are no truly non-allergenic latex products. Choice C is irrelevant to the situation described in the question, as the child does not have asthma. Choice D is also incorrect because desensitization is not an immediate option for managing a suspected latex allergy.

3. Which physiological acid-base balance complication would be most important for the nurse to assess in a patient with diarrhea?

• A. High serum pH
• B. Normal serum pH
• C. Metabolic alkalosis
• D. Metabolic acidosis

Correct answer: D

Rationale: The correct answer is metabolic acidosis. Diarrhea can lead to the loss of bicarbonate, causing an imbalance in the acid-base status of the body, specifically resulting in metabolic acidosis. High serum pH (choice A) is incorrect as diarrhea-induced bicarbonate loss would lower pH, not increase it. Normal serum pH (choice B) is not the best answer as diarrhea can disrupt the acid-base balance. Metabolic alkalosis (choice C) is an alkaline state, which is less likely to be caused by diarrhea.

4. What is an appropriate play activity for a 7-month-old infant to encourage visual stimulation?

• A. Playing peek-a-boo
• B. Playing pat-a-cake
• C. Imitating animal sounds
• D. Showing how to clap hands

Correct answer: A

Rationale: Playing peek-a-boo is an ideal play activity for a 7-month-old as it encourages visual tracking and social interaction, which are key developmental milestones at this age.

5. 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.

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