Nursing Elites

1. Which statement regarding bottle mouth caries requires further teaching?

• A. Caries can be decreased by putting an infant to bed with a bottle of milk or sweetened juice
• B. Eliminating the bedtime bottle or substituting water is recommended
• C. Sugar pools within the oral cavity cause severe decay
• D. It is often seen in children between 18 months and 3 years

Correct answer: A

Rationale: The correct answer is A. Putting an infant to bed with a bottle of milk or sweetened juice increases the risk of bottle mouth caries rather than decreasing it. This statement requires further teaching as it provides incorrect information. Choice B is correct as eliminating the bedtime bottle or substituting water is recommended to prevent bottle mouth caries. Choice C is also correct as sugar pooling within the oral cavity can indeed cause severe decay. Choice D is correct as bottle mouth caries is often observed in children between 18 months and 3 years.

2. What tool would be most useful to assess maternal and newborn attachment behaviors?

• A. Apgar
• B. Ballard scale
• C. NCAST (Nursing Child Assessment Satellite Training) Feeding Scale
• D. Brazelton Neonatal Behavioral Assessment Scale

Correct answer: C

Rationale: The NCAST Feeding Scale is the most suitable tool to evaluate maternal and newborn attachment behaviors during feedings. It focuses on observing the interaction between the parent and infant, providing insights into their bonding. The Apgar score is used to assess a neonate's immediate transition to life outside the womb, not specifically maternal and newborn attachment behaviors. The Ballard scale is used to estimate gestational age, not to assess attachment behaviors. The Brazelton Neonatal Behavioral Assessment Scale is designed to evaluate a newborn's responses to various stimuli, not specifically maternal and newborn attachment behaviors.

3. The nurse is teaching a nursing student about standard precautions. Which statement made by the student indicates a need for further teaching?

• A. I will use precautions when I give an infant oral care
• B. I will use precautions when I change an infant's diaper
• C. I will use precautions when I come in contact with blood and body fluids
• D. I will use precautions when administering oral medications to a school-age child

Correct answer: D

Rationale: Standard precautions are necessary when dealing with blood, body fluids, and potentially infectious materials. They are not required for routine administration of oral medications unless there is a potential exposure risk.

4. The nurse is caring for an infant who had surgical repair of a tracheoesophageal fistula 24 hours ago. Gastrostomy feedings have not been started. What do nursing actions related to the gastrostomy tube include?

• A. Keep the tube clamped.
• B. Suction the tube as needed.
• C. Leave the tube open to gravity drainage.
• D. Secure the tube with tape.

Correct answer: C

Rationale: Leaving the gastrostomy tube open to gravity drainage prevents the accumulation of air and fluids, reducing the risk of complications such as vomiting or aspiration in the immediate postoperative period. Keeping the tube clamped or suctioning it can lead to pressure buildup, increasing the risk of complications. Securing the tube with tape is important but not the primary action related to the gastrostomy tube in this case.

5. The nurse is caring for a child with hypernatremia. The nurse evaluates the child for which signs and symptoms of hypernatremia? (Select all that apply.)

• A. All below
• B. Lethargy
• C. Oliguria
• D. Intense thirst

Correct answer: A

Rationale: Hypernatremia typically presents with lethargy, oliguria, and intense thirst due to the body's attempt to conserve water. Apathy can also occur, but lethargy and thirst are more consistent indicators.

Similar Questions