Nursing Elites

1. Which parental statement indicates correct understanding of preventive techniques for heat-related illnesses when children exercise?

• A. Wearing dark clothing during exercise is not recommended.
• B. Water is the preferred fluid for fluid replenishment.
• C. During activity, stopping for fluids every 15 to 20 minutes is essential.
• D. Hydration should be maintained throughout the exercise session.

Correct answer: C

Rationale: The correct preventive technique for heat-related illnesses during exercise is to stop for fluids every 15 to 20 minutes to prevent dehydration and maintain hydration levels. This practice helps regulate body temperature and prevent heat-related complications. Choice A is incorrect as wearing light-colored, loose-fitting clothing is recommended to reflect sunlight and allow better air circulation. Choice B is incorrect as while water is important, a sports drink containing electrolytes may be more beneficial for longer exercise sessions. Choice D is incorrect as it does not emphasize the importance of regular fluid intake during exercise to prevent dehydration.

2. When preparing to insert an intravenous catheter for a 7-year-old child, which of the following actions should a healthcare professional take?

• A. Apply an anesthetic cream to the insertion site 1 hr before the procedure.
• B. Use a 16-gauge needle for the insertion.
• C. Insert the catheter into a vein of the child's dominant hand.
• D. Choose a site over the child's metacarpal veins.

Correct answer: A

Rationale: Applying an anesthetic cream to the insertion site 1 hr before the procedure is crucial when inserting an intravenous catheter in a child to minimize pain and discomfort during the procedure. This practice is especially important in pediatric patients to ensure a more comfortable experience and improve cooperation during the insertion process. Choice B is incorrect as a 16-gauge needle is too large for a child, and a smaller gauge needle is typically used. Choice C is incorrect as the catheter should be inserted into a suitable vein, not specifically the dominant hand vein. Choice D is incorrect as metacarpal veins are usually avoided due to their small size and the potential for complications.

3. When receiving change-of-shift report for children, which child should the nurse assess first?

• A. A toddler who has a concussion and an episode of forceful vomiting
• B. An adolescent with infective endocarditis who reports having a headache
• C. An adolescent who was placed into Halo traction 1 hour ago and rates his pain at a 6 on a 0-10 scale
• D. A school-age child with acute glomerulonephritis and brown-colored urine

Correct answer: A

Rationale: The nurse should assess the toddler with a concussion and an episode of forceful vomiting first when receiving change-of-shift report for children. Forceful vomiting in a toddler with a concussion indicates increased intracranial pressure, requiring immediate assessment and intervention to prevent further complications.

4. A 9-month-old infant who is not sitting independently has been diagnosed with ataxic cerebral palsy (CP). Which clinical manifestations would the nurse expect to see in the baby?

• A. Hypotonia and muscle instability
• B. Hypertonia and persistence of primitive reflexes
• C. Tremors and exaggerated posturing
• D. Hemiplegia and hypertonia

Correct answer: A

Rationale: In ataxic cerebral palsy, the characteristic features include hypotonia (low muscle tone) and muscle instability. These manifestations contribute to the infant's difficulty in achieving independent sitting. Hypertonia (increased muscle tone) and persistence of primitive reflexes, as mentioned in option B, are more commonly associated with other types of cerebral palsy like spastic CP. Tremors and exaggerated posturing (option C) are not typical features of ataxic CP. Hemiplegia (paralysis of one side of the body) and hypertonia (increased muscle tone) mentioned in option D are more commonly seen in other types of cerebral palsy, such as spastic CP.

5. A child with a history of seizures arrives in the emergency department (ED) in status epilepticus. Which is the priority nursing action?

• A. Take vital signs.
• B. Establish an intravenous line.
• C. Perform rapid neurologic assessment.
• D. Maintain a patent airway.

Correct answer: D

Rationale: When a child with a history of seizures presents in status epilepticus, the priority nursing action is to maintain a patent airway. This is crucial to ensure proper oxygenation and ventilation. While taking vital signs, establishing an intravenous line, and performing rapid neurologic assessment are important, maintaining a patent airway takes precedence. Hypoxia can lead to serious complications, making airway management the top priority to ensure the child's safety and prevent further deterioration.

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