Nursing Elites

1. A new mother asks the nurse, 'I was told that my infant received my antibodies during pregnancy. Does that mean that my infant is protected against infections?' Which statement should the nurse make in response to the mother?

• A. The immune system of an infant is immature, and the infant is at risk for infection.
• B. The transfer of your antibodies protects your infant until the infant is 12 months old.
• C. Yes, your infant is protected from all infections.
• D. If you breastfeed, your infant is protected from infection.

Correct answer: A

Rationale: The transplacental transfer of maternal antibodies supplements the infant's weak response to infection until approximately 3 to 4 months of age. While the infant starts producing immunoglobulin (Ig) soon after birth, it only reaches about 60% of the adult IgG level, 75% of the adult IgM level, and 20% of the adult IgA level by 1 year of age. Breast milk provides additional IgA protection. Although the immune system matures during infancy, full protection against infections is not achieved until early childhood, putting the infant at risk for infections. Choice B is incorrect because maternal antibody protection typically lasts around 3 to 4 months, not until the infant is 12 months old. Choice C is incorrect as infants are not shielded from all infections due to their immature immune system. Choice D is incorrect because while breastfeeding offers extra protection, it does not guarantee complete immunity against infections.

2. A licensed practical nurse (LPN) works on an adult medical/surgical unit and has been pulled to work on the burn unit, which cares for clients of all ages. What should the LPN do?

• A. The LPN should take the assignment, but make it clear they will only care for adult clients.
• B. The LPN should take the assignment, but explain the situation to the charge nurse and ask for a quick orientation before starting.
• C. The LPN should refuse to take the assignment, as caring for the infant and child population is not within their scope of practice.
• D. The LPN should take the assignment, but ask to be paired with a more experienced LPN.

Correct answer: B

Rationale: In this scenario, it is crucial for the LPN to demonstrate flexibility and a willingness to adapt to the new assignment that involves caring for clients of all ages. While the LPN may have expertise in a specific nursing area, it is essential to be able to provide care to diverse client populations. Accepting the assignment reflects a commitment to teamwork and patient care. However, to ensure safe and competent care, the LPN should communicate with the charge nurse about the situation. Requesting a quick orientation will help the LPN familiarize themselves with the burn unit's specific requirements, equipment, and protocols. This proactive approach allows the LPN to address any concerns, ask questions, and seek necessary support, ultimately ensuring the best care for all clients in the burn unit. Choice A is incorrect because limiting care to only adult clients may not be feasible in a unit that cares for clients of all ages. Choice C is incorrect as refusing the assignment outright may not be the best approach without considering alternatives. Choice D is not the most effective option as asking to be paired with a more experienced LPN does not address the need for a quick orientation to the new unit.

3. Which of the following tasks are appropriate for an LPN to perform?

• A. Adjusting the cervical traction device of a 68-year-old client as instructed by the charge nurse.
• B. performing operation on a woman in labour
• C. Assessing a 36-year-old man newly admitted for chest pain.
• D. Obtaining an occult blood sample from a 16-year-old client with ulcerative colitis.

Correct answer: D

Rationale: Tasks appropriate for an LPN to perform include teaching, obtaining samples, and documenting. LPNs can educate clients on care practices, such as teaching a new mother how to care for her baby. Obtaining samples, like an occult blood sample, falls within the scope of an LPN's responsibilities. Assessments, especially initial assessments, should be conducted by a registered nurse or physician, making option C incorrect. Adjusting devices like a cervical traction device should be done based on direct orders from prescribing providers, not charge nurses, making option A inappropriate for an LPN's role.

4. Which of the following might be an appropriate nursing diagnosis for an epileptic client?

• A. Dysreflexia
• B. Risk for Injury
• C. Urinary Retention
• D. Unbalanced Nutrition

Correct answer: B

Rationale: The correct answer is 'Risk for Injury.' Epileptic clients are at risk for injury due to complications of seizure activity, such as falls that could lead to head trauma. 'Dysreflexia' is not typically associated with epilepsy but rather with spinal cord injury. 'Urinary Retention' is not a common nursing diagnosis for epileptic clients unless specifically indicated. 'Unbalanced Nutrition' may not be a priority nursing diagnosis compared to the immediate risk of injury in epileptic clients.

5. A client is told that his test is positive, but in fact, the client does not have the disease tested for. Which type of false report is this an example of?

• A. positive
• B. false positive
• C. negative
• D. false negative

Correct answer: B

Rationale: The correct answer is 'false positive.' A false-positive result occurs when a test result is labeled positive in error, when the actual result is negative. In this scenario, the client received a positive test result incorrectly, as he does not have the disease being tested for. Choice A ('positive') is too vague and does not specify that the result was incorrect. Choice C ('negative') is the opposite of what happened in the scenario. Choice D ('false negative') refers to a situation where a test result is labeled negative incorrectly, which is not the case in this scenario.

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