Nursing Elites

1. A nurse is providing anticipatory guidance to the parents of a newborn about feeding skills. Which of the following is not an infant's feeding skill?

• A. Pushes solid objects from mouth
• B. Eats foods that are higher in fat
• C. Begins experimenting with a spoon
• D. Eats pieces of soft, cooked food

Correct answer: B

Rationale: The correct answer is B. When discussing infant feeding skills, it is important to note that eating foods higher in fat is not considered a specific feeding skill for newborns. The typical progression of feeding skills includes pushing solid objects from the mouth, eating pieces of soft, cooked food, drinking from a cup held by another person, and experimenting with a spoon. Choices A, C, and D correspond to the expected developmental sequence of feeding skills for infants, making them incorrect answers in this context.

2. A client is receiving teaching about a high-fiber diet to manage constipation. Which statement indicates the best choice for a high-fiber diet?

• A. Eating one medium apple is a good snack option.
• B. Selecting a ½ cup of sweet potatoes for starch is a great choice.
• C. Choosing a ½ cup of bran cereal for breakfast is ideal.
• D. Opting for 1 ounce of almonds when hungry midday is recommended.

Correct answer: C

Rationale: The correct answer is C because bran cereal is a high-fiber food that can effectively alleviate constipation by promoting regular bowel movements. Option A, an apple, while a healthy snack, may not provide as much fiber as bran cereal. Option B, sweet potatoes, are nutritious but may not be as high in fiber as bran cereal. Option D, almonds, are a good source of healthy fats and protein but do not provide as much fiber as bran cereal.

3. A client with a history of asthma is admitted to the emergency department with difficulty breathing. Which of these assessments is the highest priority for the nurse to perform?

• A. Auscultation of breath sounds
• B. Measurement of peak expiratory flow
• C. Observation of the client's use of accessory muscles
• D. Assessment of the client's skin color

Correct answer: A

Rationale: Auscultation of breath sounds is the highest priority assessment in a client with a history of asthma experiencing difficulty breathing. It helps the nurse evaluate the severity of the asthma exacerbation by listening for wheezing, crackles, or decreased breath sounds. This assessment guides treatment decisions, such as administering bronchodilators or oxygen therapy. Measurement of peak expiratory flow, although important in assessing asthma severity, may not be feasible in an emergency situation where immediate intervention is needed. Observation of accessory muscle use and assessment of skin color are also important assessments in asthma exacerbation, but auscultation of breath sounds takes precedence in determining the need for urgent interventions.

4. A nurse checks a client who is on a volume-cycled ventilator. Which finding indicates that the client may need suctioning?

• A. drowsiness
• B. complaint of nausea
• C. pulse rate of 92
• D. restlessness

Correct answer: D

Rationale: Restlessness is often a sign of respiratory distress or secretion build-up, indicating the need for suctioning. While drowsiness (choice A) can be a sign of hypoxia, it is not as immediate an indication for suctioning as restlessness. Complaint of nausea (choice B) and a pulse rate of 92 (choice C) are not directly related to the need for suctioning in a client on a volume-cycled ventilator.

5. A nurse is to collect a sputum specimen for acid-fast bacillus (AFB) from a client. Which action should the nurse take first?

• A. Ask the client to cough sputum into a container
• B. Have the client take several deep breaths
• C. Provide an appropriate specimen container
• D. Assist with oral hygiene

Correct answer: D

Rationale: Assisting with oral hygiene is the essential initial step before collecting a sputum specimen for acid-fast bacillus (AFB) to prevent contamination of the sample. Ensuring the client's mouth is clean reduces the risk of introducing unwanted bacteria into the specimen. Asking the client to cough sputum into a container, having the client take deep breaths, and providing a specimen container are important steps in the specimen collection process, but they should follow ensuring proper oral hygiene.

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