Nursing Elites

1. Which muscle is contraindicated for the administration of immunizations in infants and young children?

• A. Deltoid
• B. Dorsogluteal
• C. Ventrogluteal
• D. Anterolateral thigh

Correct answer: B

Rationale: The dorsogluteal muscle is contraindicated for immunizations in infants and young children due to the risk of injury to the sciatic nerve. The anterolateral thigh is the preferred site.

2. A 13-year-old boy comes to the school nurse complaining of sudden and severe scrotal pain. He denies any trauma to the scrotum. What is the most appropriate nursing action?

• A. Refer him for immediate medical evaluation
• B. Administer analgesics and recommend scrotal support.
• C. Apply an ice bag and observe for increasing pain.
• D. Reassure the adolescent that occasional pain is common with the changes of puberty.

Correct answer: A

Rationale: Sudden and severe scrotal pain in an adolescent male is a medical emergency and may indicate testicular torsion, which requires immediate evaluation and intervention to prevent testicular loss.

3. Kimberly is having a checkup before starting kindergarten. The nurse asks her to do the “finger-to-nose test.” What is the purpose of this test?

• A. Deep tendon reflexes
• B. Cerebellar function
• C. Sensory discrimination
• D. Ability to follow directions

Correct answer: B

Rationale: The finger-to-nose test assesses cerebellar function, which is responsible for balance and coordination. The test evaluates how well the cerebellum controls motor functions and coordination. Choice A, deep tendon reflexes, is incorrect because this test does not assess reflexes but rather cerebellar function. Choice C, sensory discrimination, is incorrect as this test focuses on motor function rather than sensory abilities. Choice D, ability to follow directions, is incorrect since the test primarily assesses motor coordination and not cognitive skills related to following instructions.

4. 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.

5. The nurse observes that a newborn is having problems after birth. What should indicate a tracheoesophageal fistula?

• A. Jitteriness
• B. Meconium ileus
• C. Excessive frothy saliva
• D. Increased need for sleep

Correct answer: C

Rationale: Excessive frothy saliva is a hallmark sign of tracheoesophageal fistula. The abnormal connection between the esophagus and trachea causes difficulty in swallowing, leading to an accumulation of saliva in the mouth. This symptom is crucial for early identification and management of tracheoesophageal fistula. Choices A, B, and D are incorrect as they are not specific indicators of tracheoesophageal fistula.

Similar Questions