Nursing Elites

1. A parent asks a nurse about his infant's expected physical development during the first year of life. Which of the following information should the nurse include?

• A. A 10-month-old infant can pull up to a standing position.
• B. A 6-month-old infant can walk with assistance.
• C. A 12-month-old infant can jump with both feet.
• D. An 8-month-old infant can crawl on hands and knees.

Correct answer: A

Rationale: The correct answer is A. By 10 months, infants can typically pull up to a standing position as part of their physical development. Walking with assistance usually begins around 9-12 months, not at 6 months (choice B). Jumping with both feet is a skill that usually develops around 24 months, not at 12 months (choice C). Crawling on hands and knees typically starts around 6-9 months, not at 8 months (choice D). Therefore, the most accurate information to include for an infant's expected physical development at 10 months is the ability to pull up to a standing position.

2. When assessing a client's IV for infiltration, which finding would be unexpected for the nurse?

• A. The area around the infusion site feels warm to the touch.
• B. The infusion site is swollen and cool to the touch.
• C. The infusion line does not flush properly.
• D. There is no blood return in the infusion line.

Correct answer: A

Rationale: The correct answer is A. Warmth around the infusion site is not an expected finding with infiltration. Infiltration typically presents with swelling and coolness due to the fluid leaking into the surrounding tissue. Choices B, C, and D are incorrect because swelling, coolness, and difficulty flushing the line, as well as lack of blood return, are commonly associated with infiltration.

3. Which statement by the mother indicates that the mother understands safety precautions with her four-month-old infant and her 4-year-old child?

• A. I secure the infant car seat in the back seat facing backwards.
• B. I place my infant in the middle of the living room floor on a blanket to play with my 4-year-old while I make supper in the kitchen.
• C. My sleeping baby looks adorable in the crib with the little buttocks up in the air while the four-year-old naps on the sofa.
• D. I have the 4-year-old hold and help feed the four-month-old a bottle in the kitchen while I make supper.

Correct answer: D

Rationale: Choice D is the correct answer because having the 4-year-old help feed the four-month-old a bottle in the kitchen while the mother makes supper shows supervision of the infant by the older child in a safe environment. This choice indicates that the mother understands safety precautions by involving the older child in a caregiving task under her supervision. Choices A, B, and C are incorrect because they involve unsafe practices such as placing the infant on the floor unsupervised, positioning the infant car seat in the front seat, and not providing direct supervision of the children during naptimes.

4. The healthcare provider is caring for a client receiving chemotherapy. Which finding should the LPN/LVN report to the healthcare provider immediately?

• A. Mild nausea
• B. Hair loss
• C. Increased fatigue
• D. Fever of 101.5°F (38.6°C)

Correct answer: D

Rationale: A fever of 101.5°F (38.6°C) in a client undergoing chemotherapy is a significant finding that may indicate an underlying infection, which can be life-threatening due to the client's compromised immune system. Prompt reporting and intervention are crucial to prevent complications. Mild nausea, hair loss, and increased fatigue are common side effects of chemotherapy and are expected findings that do not typically require immediate reporting unless they are severe or significantly impacting the client's well-being. Therefore, the LPN/LVN should prioritize reporting the fever over the other options.

5. A client is admitted with a diagnosis of septicemia. Which assessment finding should the LPN/LVN report to the healthcare provider immediately?

• A. Increased urine output
• B. Decreased blood pressure
• C. Increased heart rate
• D. Increased respiratory rate

Correct answer: B

Rationale: In a client with septicemia, decreased blood pressure is a critical finding that suggests potential septic shock, a life-threatening condition. Septic shock requires immediate medical intervention to prevent further deterioration and organ dysfunction. Increased urine output (Choice A) may indicate adequate fluid resuscitation, which is a positive response. Increased heart rate (Choice C) and increased respiratory rate (Choice D) are common physiological responses to sepsis and do not necessarily indicate immediate life-threatening complications like decreased blood pressure does in septic shock.

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