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 providing oral care for an unconscious client, which of the following actions should the nurse take?

• A. Place the client in a lateral position with the head turned to the side before beginning the procedure.
• B. Insert a suction catheter before brushing the teeth.
• C. Use a soft-bristled toothbrush only with water.
• D. Brush the client's teeth while they are in a supine position.

Correct answer: A

Rationale: When providing oral care for an unconscious client, it is essential to place them in a lateral position with the head turned to the side before beginning the procedure. This positioning helps prevent aspiration by allowing fluids to drain out of the mouth, reducing the risk of choking or aspiration pneumonia. Inserting a suction catheter before brushing the teeth (Choice B) is not recommended as it can cause discomfort and increase the risk of oral tissue injury. Using a soft-bristled toothbrush only with water (Choice C) is not sufficient for effective oral care as toothpaste helps in removing plaque and bacteria. Brushing the client's teeth while they are in a supine position (Choice D) is not safe as it increases the risk of aspiration since fluids can easily enter the airway in this position.

3. A charge nurse is discussing the responsibility of nurses caring for clients who have a Clostridium difficile infection. Which of the following information should the nurse include in the teaching?

• A. Assign the client to a room with a negative air-flow system.
• B. Use alcohol-based hand sanitizer when leaving the client's room.
• C. Clean contaminated surfaces in the client's room with a phenol solution.
• D. Have family members wear a gown and gloves when visiting.

Correct answer: D

Rationale: When caring for clients with Clostridium difficile infection, it is important to prevent the transmission of spores. Having family members wear a gown and gloves when visiting helps reduce the spread of the infection. Choices A, B, and C are incorrect because assigning the client to a room with a negative air-flow system, using alcohol-based hand sanitizer, and cleaning surfaces with a phenol solution are not specific measures targeted at preventing the transmission of Clostridium difficile spores.

4. A nurse questions a medication prescription as too extreme in light of the client’s advanced age and unstable status. The nurse understands that this action is an example of which of the following ethical principles?

• A. Fidelity
• B. Autonomy
• C. Justice
• D. Nonmaleficence

Correct answer: D

Rationale: The correct answer is D, Nonmaleficence. Nonmaleficence refers to the principle of 'do no harm.' In this scenario, questioning a potentially harmful prescription for a client with advanced age and unstable status aligns with the principle of nonmaleficence, as the nurse is advocating for the client's safety and well-being. Choice A, Fidelity, refers to being faithful and keeping promises, which is not directly related to the situation described. Choice B, Autonomy, pertains to respecting a patient's right to make their own decisions, which is not the focus of the nurse questioning the prescription. Choice C, Justice, involves fairness and equal treatment, which is not the primary ethical principle at play in this situation.

5. The client is being taught about the use of syringes and needles for home administration of medications. Which action by the client indicates an understanding of standard precautions?

• A. Remove the needle after discarding used syringes
• B. Wear gloves while disposing of the needle and syringe
• C. Wear a face mask during medication administration
• D. Wash hands before handling the needle and syringe

Correct answer: D

Rationale: The correct answer is D. Washing hands before handling the needle and syringe is a critical step in infection control and adherence to standard precautions. Clean hands help prevent the transfer of microorganisms and reduce the risk of infection. Choices A, B, and C do not directly relate to standard precautions. Removing the needle after discarding used syringes (Choice A) can increase the risk of needlestick injuries. Wearing gloves while disposing of the needle and syringe (Choice B) is important for personal protection but does not specifically address standard precautions. Wearing a face mask during medication administration (Choice C) is not directly related to handling syringes and needles, which are more pertinent to standard precautions.

Similar Questions