Nursing Elites

1. What is the earliest age at which a satisfactory radial pulse can be taken in children?

• A. 1 year
• B. 2 years
• C. 3 years
• D. 6 years

Correct answer: C

Rationale: A satisfactory radial pulse can typically be taken starting at around 3 years of age, as younger children often have pulses that are too fast and irregular for accurate measurement.

2. What is an appropriate nursing intervention for a child with minimal change nephrotic syndrome (MCNS) who has scrotal edema?

• A. Place an ice pack on the scrotal area.
• B. Place the child in an upright sitting position.
• C. Elevate the scrotum with a rolled washcloth.
• D. Place a warm moist pack to the scrotal area.

Correct answer: C

Rationale: Elevating the scrotum with a rolled washcloth helps reduce edema by promoting fluid drainage. Ice packs are not recommended due to the risk of frostbite, and warm moist packs are not typically used for this purpose. An upright position does not specifically address the edema.

3. What is an essential nursing care intervention for a neonate with a suspected tracheoesophageal fistula?

• A. Feed glucose water only.
• B. Elevate the patient's head for feedings.
• C. Raise the patient's head and give nothing by mouth.
• D. Avoid suctioning unless the infant is cyanotic.

Correct answer: C

Rationale: Raising the patient’s head and giving nothing by mouth is crucial in managing tracheoesophageal fistula. This intervention helps prevent aspiration and further complications until surgical correction can be performed. Feeding the neonate or suctioning could exacerbate the condition by risking aspiration. Elevating the head for feedings does not address the primary concern of preventing oral intake, making it less appropriate than the correct answer.

4. The child is admitted to the hospital unit newly diagnosed with retinoblastoma. Which clinical manifestation does the nurse anticipate upon assessment?

• A. A white reflex
• B. Blue-tinged sclerae
• C. A red reflex
• D. Yellow-tinged sclerae

Correct answer: A

Rationale: The correct answer is A: A white reflex. The 'white reflex' or leukocoria is a common sign of retinoblastoma. It occurs when the light reflects off the tumor in the eye, giving the pupil a white appearance instead of the normal red reflex. Blue-tinged sclerae (choice B) and yellow-tinged sclerae (choice D) are not typical manifestations of retinoblastoma. A red reflex (choice C) is the normal reflection seen in the eye when light is shone on it and is not associated with retinoblastoma.

5. Which immunization is typically administered at birth?

• A. Hepatitis B
• B. DTaP
• C. MMR
• D. Varicella

Correct answer: A

Rationale: The correct answer is A, Hepatitis B. The Hepatitis B vaccine is usually given at birth to protect against hepatitis B, a virus that can lead to chronic liver disease and liver cancer. This vaccination is crucial for newborns, especially those born to mothers who are carriers of hepatitis B. Choices B, C, and D are incorrect because DTaP (B), MMR (C), and Varicella (D) vaccines are not typically administered at birth. DTaP is given in a series starting at 2 months, MMR is usually given around 12-15 months, and Varicella is given between 12-15 months of age.

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