Nursing Elites

1. When the nurse interviews an adolescent, which is especially important?

• A. Focus the discussion on the peer group
• B. Allow an opportunity to express feelings
• C. Use the same type of language as the adolescent
• D. Emphasize that confidentiality will always be maintained

Correct answer: B

Rationale: Allowing adolescents to express their feelings helps them feel heard and supported, which is crucial for effective communication.

2. During the 2-month well-child checkup, the nurse expects the infant to respond to sound in which manner?

• A. Respond to name
• B. React to loud noise with Moro reflex
• C. Turn his or her head to side when sound is at ear level
• D. Locate sound by turning his or her head in a curving arc

Correct answer: B

Rationale: At 2 months, infants typically react to loud noises with the Moro reflex, a startle response that is normal at this stage of development.

3. The parent of an 8.2-kg (18-lb) 9-month-old infant is borrowing a federally approved car seat from the clinic. The nurse should explain that the safest way to put in the car seat is what?

• A. Front facing in back seat
• B. Rear facing in back seat
• C. Front facing in front seat with air bag on passenger side
• D. Rear facing in front seat if an air bag is on the passenger side

Correct answer: B

Rationale: Infants should be placed rear-facing in the back seat until they are at least 2 years old or exceed the weight/height limit of their car seat for optimal safety.

4. After surgery yesterday for gastroesophageal reflux, the nurse finds that the infant has somehow removed the nasogastric (NG) tube. What nursing action is most appropriate to perform at this time?

• A. Notify the healthcare provider.
• B. Insert a new NG tube for feedings.
• C. Replace the NG tube to maintain gastric decompression.
• D. Leave the NG tube out as it may have been in long enough.

Correct answer: A

Rationale: The most appropriate action for the nurse to take in this situation is to notify the healthcare provider immediately. This is important as the removal of the NG tube can disrupt postoperative care, especially in terms of maintaining gastric decompression. Inserting a new NG tube without practitioner direction can be unsafe and is not within the nurse's scope of practice. Similarly, replacing the NG tube or leaving it out should be decided by the healthcare provider to ensure the infant's safety and appropriate postoperative care.

5. A child with acute gastrointestinal bleeding is admitted to the hospital. The nurse observes which sign or symptom as an early manifestation of shock?

• A. Restlessness
• B. Rapid capillary refill
• C. Increased temperature
• D. Increased blood pressure

Correct answer: A

Rationale: Restlessness is an early sign of shock due to decreased perfusion and oxygenation to the brain. This symptom requires immediate attention to prevent the progression to more severe stages of shock. Rapid capillary refill (Choice B) is not typically an early sign of shock but rather a sign of adequate perfusion. Increased temperature (Choice C) may occur in later stages of shock due to the body's response to stress. Increased blood pressure (Choice D) is not an early sign of shock; in fact, blood pressure tends to decrease in shock as a compensatory mechanism.

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