Nursing Elites

1. A nurse is preparing to measure the temperature of an infant. Which of the following actions should the nurse take?

• A. Place the tip of the thermometer under the center of the infant's axilla.
• B. Pull the pinna of the infant's ear forward before inserting the probe.
• C. Insert the probe 3.8 cm (1.5 inches) into the infant's rectum.
• D. Insert the thermometer in front of the infant's tongue.

Correct answer: A

Rationale: The correct method for measuring an infant's temperature is by placing the tip of the thermometer under the center of the infant's axilla (armpit). This method is non-invasive and safe. Pulling the pinna of the ear forward is used when taking a tympanic temperature. Inserting the probe into the rectum is done for rectal temperature measurement, which is not recommended as an initial method in infants. Inserting the thermometer in front of the infant's tongue is not a standard method for measuring temperature in infants.

2. In an emergency department following a community disaster, a healthcare provider is performing triage for multiple clients. To which of the following types of injuries should the provider assign the highest priority?

• A. Below-the-knee amputation.
• B. Fractured tibia.
• C. 95% full-thickness body burn.
• D. 10 cm laceration to the forearm.

Correct answer: A

Rationale: During disaster triage, clients with severe injuries that are immediately life-threatening and have a high likelihood of mortality without intervention are assigned the highest priority. A below-the-knee amputation falls into this category as it indicates a critical injury that requires immediate attention to prevent further complications or loss of life. Fractured tibia, a 95% full-thickness body burn, and a 10 cm laceration to the forearm, while serious, do not pose the same level of immediate life-threatening risk as a below-the-knee amputation in the context of disaster triage.

3. Which lab value is critical for monitoring warfarin therapy?

• A. Monitor INR
• B. Monitor platelet count
• C. Monitor sodium levels
• D. Monitor calcium levels

Correct answer: A

Rationale: The correct answer is A: Monitor INR. INR (International Normalized Ratio) is crucial for monitoring warfarin therapy as it helps assess the therapeutic effectiveness and bleeding risks associated with the medication. INR measures the clotting tendency of blood, which is essential in determining the appropriate dosage of warfarin. Monitoring platelet count (B), sodium levels (C), or calcium levels (D) is not primarily used for assessing warfarin therapy. Platelet count is more relevant in assessing bleeding disorders, while sodium and calcium levels are typically monitored for different medical conditions unrelated to warfarin therapy.

4. A nurse is caring for a client who has a history of angina. The client reports chest pain. Which of the following actions should the nurse take?

• A. Administer sublingual nitroglycerin every 5 minutes
• B. Administer aspirin 325 mg
• C. Encourage the client to use deep breathing exercises
• D. Apply oxygen at 2 L/min via nasal cannula

Correct answer: A

Rationale: The correct action for the nurse to take when a client with a history of angina reports chest pain is to administer sublingual nitroglycerin every 5 minutes. Nitroglycerin helps dilate blood vessels, improving blood flow to the heart and relieving chest pain associated with angina. Aspirin is often given during a suspected heart attack, not for immediate relief of angina. Deep breathing exercises may be beneficial for anxiety or respiratory conditions but are not the first-line intervention for angina. Oxygen therapy is not the initial treatment for angina unless the client is hypoxic.

5. A healthcare provider is assessing a client who has acute pancreatitis. Which of the following laboratory results should the healthcare provider expect to be elevated?

• A. Serum sodium.
• B. Serum calcium.
• C. Serum glucose.
• D. Serum amylase.

Correct answer: D

Rationale: Serum amylase levels are typically elevated in clients with acute pancreatitis as it is an enzyme released by the pancreas. Elevated serum sodium, calcium, or glucose levels are not typically associated with acute pancreatitis. Therefore, choices A, B, and C are incorrect.

Similar Questions