Nursing Elites

1. Which type of breath sound is normally heard over the entire surface of the lungs except for the upper intrascapular area and the area beneath the manubrium?

• A. Vesicular
• B. Bronchial
• C. Adventitious
• D. Bronchovesicular

Correct answer: A

Rationale: Vesicular breath sounds are normally heard over most of the lung fields, except near the trachea and main bronchi, where bronchial or bronchovesicular sounds may be heard.

2. The nurse is educating a new nurse on the identification of pain in children. What does the nurse teach about physiologic measurements in children’s pain assessment?

• A. Not useful as the only indicator for pain
• B. Best indicator of pain in children of all ages
• C. Most valuable when children also report having pain
• D. Essential to determine whether a child is telling the truth about pain

Correct answer: A

Rationale: Physiologic manifestations of pain may vary considerably, so they do not provide a consistent measure of pain. Heart rate may increase or decrease. The same signs that may suggest fear, anxiety, or anger also indicate pain. In chronic pain, the body adapts, and these signs decrease or stabilize. Physiologic measurements are of limited value and must be viewed in the context of a pain rating scale, behavioral assessment, and parental report. When the child reports pain on an appropriate pain scale, the appropriate interventions should be used. Therefore, physiologic measurements are not considered a reliable standalone indicator for pain in children, making choice A the correct answer. Choice B is incorrect because physiologic measurements alone do not serve as the best indicator of pain. Choice C is incorrect as physiologic measurements are still limited even when children report pain. Choice D is incorrect as physiologic measurements are not primarily used to determine the truthfulness of a child's pain report.

3. The nurse is caring for a child with an order of Ampicillin 250 mg IV in 30 mL of Normal Saline to infuse over 30 minutes. How many mL/hour should the nurse set the pump?

• A. 60
• B. 30
• C. 120
• D. 15

Correct answer: A

Rationale: The correct setting for the infusion pump should be 60 mL/hour to deliver 30 mL in 30 minutes. To calculate the infusion rate in mL/hour, divide the total volume to be infused (30 mL) by the total time for infusion (30 minutes) and then multiply by 60 to convert minutes to hours. Therefore, 30 mL / 30 minutes * 60 minutes/hour = 60 mL/hour. Choices B, C, and D are incorrect because they do not match the calculation based on the given parameters.

4. A child is refusing to use the potty and having accidents, even though he has achieved toilet training. This is an example of which type of behavior?

• A. Positive reinforcement
• B. Desensitization
• C. Phobia
• D. Regression

Correct answer: D

Rationale: The correct answer is D, regression. Regression occurs when a child reverts to an earlier behavior, such as having accidents after being successfully toilet trained. This regression often happens due to stress or changes in routine. Choices A, B, and C are incorrect because positive reinforcement involves encouraging desired behavior, desensitization is a process of reducing sensitivity to a stimulus, and phobia is an intense fear or aversion to a specific object or situation, none of which directly apply to the described situation of the child having accidents after being toilet trained.

5. When assessing an infant with intussusception, what type of stool would the nurse expect to find?

• A. Soft, seedy stool
• B. Currant-jelly stool
• C. Ribbon-like stool
• D. Soft and pasty stool

Correct answer: B

Rationale: The correct answer is B: Currant-jelly stool. This type of stool, which is red and mucous-like, is a classic sign of intussusception in infants. Choice A (Soft, seedy stool) is incorrect as it does not specifically describe the characteristic stool associated with intussusception. Choice C (Ribbon-like stool) is incorrect; ribbon-like stool may be seen in conditions like colon cancer, not intussusception. Choice D (Soft and pasty stool) is also incorrect as it does not match the typical stool finding in intussusception.

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