Nursing Elites

1. When caring for a child with an intravenous (IV) infusion, what is an appropriate nursing action?

• A. Change the insertion site every 24 hours.
• B. Check the insertion site frequently for signs of infiltration.
• C. Use a macrodropper to facilitate reaching the prescribed flow rate.
• D. Avoid restraining the child to prevent undue emotional stress.

Correct answer: B

Rationale: Frequent monitoring of the IV site for signs of infiltration is crucial to prevent tissue damage, especially in pediatric patients. Changing the site every 24 hours is unnecessary unless complications arise, and using a macrodropper is not specific to pediatric care.

2. When taking a child’s blood pressure, what percentage of the upper arm should the nurse ensure the cuff bladder width covers?

• A. 20%
• B. 40%
• C. 60%
• D. 80%

Correct answer: B

Rationale: When taking a child's blood pressure, the nurse should select a cuff with a bladder width that covers 40% of the arm circumference at the midpoint of the upper arm. This ensures accurate readings. Choosing a cuff that covers less or more than 40% can lead to incorrect blood pressure measurements. Therefore, options A, C, and D are incorrect.

3. A parent and 4-year-old child are waiting in an exam room when the nurse enters and greets them. Which activity that the nurse observes the child doing would best demonstrate the primary developmental task of the preschool-age child, according to Erikson?

• A. Reading a book
• B. Singing a song he learned at preschool
• C. Opening drawers in the room, pulling out supplies, and examining them
• D. Roughhousing with the parent

Correct answer: C

Rationale: The correct answer is C. According to Erikson, the primary task of a preschool-aged child is to explore and assert control over their environment. This behavior is demonstrated by the child opening drawers, pulling out supplies, and examining them, showcasing curiosity and exploration. Choices A, B, and D do not align with the primary developmental task of a preschool-age child according to Erikson. Reading a book and singing a song are more passive activities, while roughhousing with the parent does not directly relate to exploration and asserting control over the environment.

4. The mother of an infant diagnosed with bronchiolitis asks the nurse what causes the disease. How should the nurse respond?

• A. Respiratory syncytial virus (RSV)
• B. Haemophilus influenzae
• C. Parainfluenza
• D. Rotavirus

Correct answer: A

Rationale: The correct answer is A: Respiratory syncytial virus (RSV). RSV is the most common cause of bronchiolitis, especially in infants. Bronchiolitis is characterized by inflammation of the small airways in the lungs. Choice B, Haemophilus influenzae, is a bacterium that can cause respiratory infections but is not the primary cause of bronchiolitis. Choice C, Parainfluenza, is a common viral infection that can cause croup and other respiratory illnesses but is not the main cause of bronchiolitis. Choice D, Rotavirus, is a virus that primarily affects the gastrointestinal system, causing diarrhea and vomiting, and is not associated with bronchiolitis.

5. The nurse is performing an assessment on a 10-week-old infant. The nurse understands that the developmental characteristic of hearing at this age is which?

• A. The infant responds to his own name.
• B. The infant localizes sounds by turning his head directly to the sound.
• C. The infant turns his head to the side when sound is made at the level of the ear.
• D. The infant locates sound by turning his head to the side and then looking up or down.

Correct answer: C

Rationale: By 10 weeks, infants typically turn their heads to the side to locate the source of a sound made at ear level.

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