Nursing Elites

1. A caregiver is caring for a 5-month-old infant who has manifestations of severe dehydration and a prescription for parenteral fluid therapy. The caregiver asks, 'What are the indications that my baby needs an IV?' Which of the following responses should the caregiver make?

• A. Your baby needs an IV because she is not producing any tears
• B. Your baby needs an IV because her fontanels are bulging
• C. Your baby needs an IV because she is breathing slower than normal
• D. Your baby needs an IV because her heart rate is decreasing

Correct answer: A

Rationale: The correct response is A: 'Your baby needs an IV because she is not producing any tears.' In infants, the inability to produce tears is a sign of severe dehydration. This is a crucial indication for the need for intravenous (IV) fluid therapy to rehydrate the infant. While the other options may also be symptoms of dehydration, the absence of tears is a more direct and specific indicator requiring immediate attention and intervention.

2. A 38-year-old patient’s vital signs at 8 a.m. are axillary temperature 99.6°F (37.6°C); pulse rate 88; respiratory rate 30. Which findings should be reported?

• A. Respiratory rate only
• B. Temperature only
• C. Pulse rate and temperature
• D. Temperature and respiratory rate

Correct answer: D

Rationale: Both an elevated temperature and an increased respiratory rate are abnormal vital signs that could indicate an underlying health issue. Reporting both of these findings is crucial to ensure appropriate evaluation and intervention if needed.

3. A client had oral surgery following a motor vehicle accident. The nurse assessing the client finds the skin flushed and warm. Which of the following would be the best method to take the client’s body temperature?

• A. Oral
• B. Axillary
• C. Arterial line
• D. Rectal

Correct answer: D

Rationale: In cases where the oral route is contraindicated due to oral surgery or altered consciousness, the rectal method is preferred for the most accurate body temperature reading. This method is particularly useful when the skin is flushed and warm, as it provides a reliable reflection of core body temperature despite external factors affecting the skin temperature. Axillary temperature may not be as accurate as rectal temperature due to variations caused by environmental factors and technique. Arterial line temperature monitoring is invasive and not typically used for routine temperature assessment.

4. A client is being instructed on the use of an incentive spirometer. Which of the following statements by the client indicates an understanding of the teaching?

• A. ''I will place the adapter on my finger to read my blood oxygen saturation level.''
• B. ''I will lie on my back with my knees bent.''
• C. ''I will rest my hand over my abdomen to create resistance.''
• D. ''I will take in a deep breath and hold it before exhaling.''

Correct answer: D

Rationale: The correct answer demonstrates an understanding of the proper technique for using an incentive spirometer. Incentive spirometry helps to improve lung function by encouraging deep breathing and sustaining the inhalation to fully expand the lungs. Options A, B, and C are incorrect because they do not reflect the correct instructions for using an incentive spirometer.

5. In which of the following organs does the exchange of gases take place?

• A. Kidneys
• B. Lungs
• C. Liver
• D. Heart

Correct answer: B

Rationale: The exchange of gases, specifically oxygen and carbon dioxide, occurs in the lungs. In the lungs, oxygen from the air we breathe enters the bloodstream, while carbon dioxide is removed from the bloodstream and exhaled. This process is essential for respiration and supplying the body with oxygen for energy production. The kidneys filter waste from the blood to produce urine and regulate fluid balance (Choice A). The liver is involved in detoxification, protein synthesis, and producing bile (Choice C). The heart is responsible for pumping blood throughout the body to deliver oxygen and nutrients (Choice D).

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