Nursing Elites

1. You arrive at the scene shortly after a 3-year-old female experienced a seizure. The child, who is being held by her mother, is conscious and crying. The mother tells you that her daughter has been ill recently and has a temperature of 102.5°F. What is the MOST appropriate treatment for this child?

• A. Oxygen via non-rebreathing mask, place the child in a tub of cold water to lower her body temperature, and transport.
• B. Oxygen via the blow-by technique, transport, and request a paramedic intercept so an anticonvulsant drug can be given.
• C. Oxygen via non-rebreathing mask, avoid any measures to lower the child's body temperature, and transport at once.
• D. Oxygen via the blow-by technique, remove clothing to help reduce her fever, and transport with continuous monitoring.

Correct answer: D

Rationale: The most appropriate treatment for a child who has experienced a seizure and has a fever includes administering oxygen via the blow-by technique, removing clothing to help reduce fever, and transporting the child with continuous monitoring. Choice A is incorrect because placing the child in a tub of cold water can lead to hypothermia and is not recommended for fever reduction. Choice B is incorrect as requesting an anticonvulsant drug without proper evaluation and assessment by a healthcare provider is not appropriate. Choice C is incorrect as avoiding measures to lower the child's body temperature can worsen the situation in case of febrile seizures. Therefore, the best course of action is to provide oxygen via the blow-by technique, remove excess clothing to reduce fever, and transport the child while continuously monitoring her condition.

2. Which pain assessment tool is most appropriate for a 3-month-old hospitalized with a fractured femur?

• A. FLACC scale
• B. Poker chip tool
• C. Number scale
• D. Visual analog scale

Correct answer: A

Rationale: The FLACC scale, which stands for Face, Legs, Activity, Cry, and Consolability, is specifically designed for nonverbal patients like infants and young children. It assesses pain based on observable behaviors such as facial expressions, leg movement, activity level, cry, and the ability to be consoled. In this case, a 3-month-old infant who is unable to communicate verbally would best be assessed using the FLACC scale to determine the level of pain experienced due to a fractured femur. The Poker chip tool, Number scale, and Visual analog scale are not suitable for nonverbal infants and young children as they rely on self-reporting or cognitive abilities that are not yet developed at this age.

3. What is the most appropriate action to prevent heat loss in a newborn immediately after birth?

• A. Place the newborn in an incubator
• B. Bathe the newborn right away
• C. Dry the newborn thoroughly
• D. Feed the newborn

Correct answer: C

Rationale: Drying the newborn thoroughly is the most appropriate action to prevent heat loss immediately after birth. This helps to prevent heat loss through evaporation, which is crucial in maintaining the newborn's body temperature. Placing the newborn in an incubator can be a secondary step after ensuring the baby is dry. Bathing the newborn right away is not recommended as it can lead to further heat loss through evaporation. Feeding the newborn is important but not an immediate action to prevent heat loss; ensuring the baby is dry and warm takes precedence.

4. Kobby, who is diagnosed with diabetes mellitus type 1, displays symptoms of hypoglycemia; which of the following actions should the nurse instruct the parents to take?

• A. Give the child honey (simple sugar)
• B. Give the child milk (complex sugar)
• C. Contact the healthcare provider before doing anything
• D. Give the child nothing by mouth

Correct answer: A

Rationale: During hypoglycemia, it is crucial to quickly raise blood glucose levels. Giving a simple sugar like honey is recommended as it can rapidly increase blood sugar levels and alleviate the symptoms of hypoglycemia in individuals with diabetes mellitus type 1. Milk, being a complex sugar, will not act as quickly as honey in raising blood sugar levels. Contacting the healthcare provider may lead to a delay in treatment, as immediate action is necessary during hypoglycemia. Withholding food or drink (choice D) is not appropriate when dealing with hypoglycemia as it can worsen the condition.

5. What should the nurse include in the insulin administration instruction for the parents of a child being discharged on insulin?

• A. Insert the needle and aspirate before injecting
• B. Inject insulin into the extremity to be exercised to improve absorption
• C. The muscles in the abdomen and thigh are the easiest for self-administration
• D. Clean the injection site with soap and water and avoid alcohol

Correct answer: C

Rationale: The correct answer is C because the muscles in the abdomen and thigh are the most suitable areas for self-administration of insulin due to consistent absorption. Choices A and B are incorrect as aspirating before injecting insulin is unnecessary, and injecting into an extremity to be exercised does not enhance absorption. Choice D is incorrect as alcohol should be used to clean the injection site instead of soap and water, which can cause skin irritation.

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