Nursing Elites

1. Which best describes a full-thickness (third-degree) burn?

• A. Erythema and pain
• B. Skin showing erythema followed by blister formation
• C. Destruction of all layers of skin evident with extension into subcutaneous tissue
• D. Destruction injury involving underlying structures such as muscle, fascia, and bone

Correct answer: C

Rationale: A full-thickness (third-degree) burn involves the destruction of all layers of skin, including the epidermis, dermis, and extending into the subcutaneous tissue. This type of burn results in significant tissue damage and can appear pale, charred, or leathery. Choice A is incorrect as erythema and pain are more characteristic of superficial burns. Choice B describes a partial-thickness burn where the skin shows erythema followed by blister formation, involving the epidermis and part of the dermis. Choice D is incorrect as it describes a deeper type of injury involving structures beyond the skin layers, such as muscle, fascia, and bone, which is not specific to a full-thickness burn.

2. A parent and 3-month-old infant are visiting the well-baby clinic for a routine examination. What should the nurse include in the accident prevention teaching plan?

• A. Remove small objects from the floor.
• B. Cover electric outlets with safety plugs.
• C. Remove toxic substances from low areas.
• D. Test the temperature of water before bathing.

Correct answer: D

Rationale: The correct answer is to test the temperature of water before bathing. This is crucial in preventing burns, which is a significant risk for infants due to their sensitive skin. Infants have delicate skin that can be easily burned by water that is too hot. Removing small objects from the floor (Choice A) is important to prevent choking hazards but not directly related to burns. Covering electric outlets with safety plugs (Choice B) is essential to prevent electrocution but does not address the risk of burns specifically. Removing toxic substances from low areas (Choice C) is necessary to prevent poisoning but is not directly related to burns. Therefore, the priority in this scenario is to prevent burns by ensuring the water temperature is safe for the infant.

3. The nurse is implementing care for a school-age child admitted to the pediatric intensive care unit with diabetic ketoacidosis (DKA). Which prescribed intervention should the nurse implement first?

• A. Begin 0.9% saline solution intravenously as prescribed
• B. Administer regular insulin intravenously as prescribed
• C. Place the child on a cardiac monitor
• D. Place the child on a pulse oximetry monitor

Correct answer: A

Rationale: The correct first intervention when managing a child with diabetic ketoacidosis is to begin intravenous saline solution to address dehydration and restore electrolyte balance. Rehydration is essential to improve perfusion and correct electrolyte imbalances. Administering insulin without addressing dehydration can potentially lead to further complications. Placing the child on a cardiac monitor or pulse oximetry monitor is important but not the initial priority in managing DKA.

4. A nurse is assessing a child with suspected rotavirus infection. What clinical manifestation is the nurse likely to observe?

• A. Abdominal pain
• B. Diarrhea
• C. Constipation
• D. Vomiting

Correct answer: B

Rationale: The correct answer is B: Diarrhea. Rotavirus infection commonly presents with symptoms such as watery diarrhea, vomiting, fever, and abdominal pain. While abdominal pain and vomiting are also associated with rotavirus infection, diarrhea is a hallmark feature. Constipation is not typically seen in cases of rotavirus infection. Therefore, the most likely clinical manifestation that the nurse would observe in a child with suspected rotavirus infection is diarrhea.

5. A nurse is providing care to a child with a diagnosis of bronchiolitis. What is the priority nursing intervention?

• A. Administering bronchodilators
• B. Providing respiratory therapy
• C. Monitoring oxygen saturation
• D. Encouraging fluid intake

Correct answer: B

Rationale: The correct answer is providing respiratory therapy. In bronchiolitis, the priority is to maintain airway patency through interventions such as suctioning, positioning, and oxygen therapy. While bronchodilators may be used in some cases, they are not the initial priority. Monitoring oxygen saturation is important but comes after ensuring airway patency. Encouraging fluid intake is essential for hydration but is not the priority over maintaining a patent airway.

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