Nursing Elites

1. When reviewing car seat use with the parents of a 1-month-old infant, which of the following instructions should the nurse include?

• A. Use a car seat that has a three-point harness system.
• B. Position the car seat so that the infant is rear-facing.
• C. Secure the car seat in the front passenger seat of the vehicle.
• D. Convert to a booster seat after 12 months.

Correct answer: B

Rationale: The correct instruction for car seat use with a 1-month-old infant is to position the car seat so that the infant is rear-facing. This orientation provides the safest option for infants as it supports their head, neck, and spine. While using a car seat with a three-point harness system is appropriate for infants, placing the car seat in the front passenger seat is not recommended due to the presence of airbags, which can pose a risk to the infant in the event of deployment. Additionally, transitioning to a booster seat is not suitable at 12 months; infants should remain in rear-facing car seats until they outgrow the seat's height or weight limits, typically around 2 years of age.

2. A nurse is observing a newly licensed nurse providing care for a client who reports pain. The nurse checked the client’s MAR and noted the last dose of pain medication was administered 6 hours ago. The prescription specifies administration every 4 hours PRN for pain. The nurse administered the medication and followed up with the client 40 minutes later, who reported improvement. What did the newly licensed nurse overlook in the nursing process?

• A. Assessment
• B. Planning
• C. Intervention
• D. Evaluation

Correct answer: A

Rationale: The correct answer is 'Assessment.' In the nursing process, assessment is the first step, crucial before any intervention. Assessment involves gathering data about the client's condition to establish a baseline for evaluating responses to interventions. In this scenario, the newly licensed nurse missed assessing the client's pain intensity, location, quality, and other relevant factors before administering the pain medication. While the follow-up evaluation with the client is commendable, it cannot replace the initial assessment. Planning involves setting goals and outcomes, intervention is the action taken to achieve these goals, and evaluation assesses the client's response to the intervention.

3. A healthcare professional is preparing to insert an NG tube for a client admitted with bowel obstruction. Which of the following should the healthcare professional do first?

• A. Explain the procedure to the client
• B. Measure the length of the NG tube
• C. Lubricate the NG tube
• D. Place the client in a high Fowler’s position

Correct answer: A

Rationale: Explaining the procedure to the client is the initial and most important step that the healthcare professional should take before inserting an NG tube. By explaining the procedure, the healthcare professional ensures the client's understanding, obtains informed consent, and fosters cooperation. Measuring the length of the NG tube, lubricating the tube, and positioning the client in a high Fowler's position are essential steps in the NG tube insertion process but should come after the client has been informed and consented to the procedure.

4. A charge nurse is observing a newly licensed nurse prepare a sterile field. Which of the following actions should the charge nurse identify as contaminating the sterile field?

• A. The nurse opens the sterile field on a wet surface.
• B. The nurse turns away from the sterile field.
• C. The nurse uses a non-sterile glove to touch the sterile field.
• D. The nurse touches the edge of the sterile drape with her hand.

Correct answer: A

Rationale: The correct answer is A. Opening the sterile field on a wet surface contaminates it, rendering it unsafe for use. Moisture can carry microorganisms that can compromise the sterility of the field. Choice B is incorrect because turning away from the sterile field alone does not necessarily contaminate it unless the nurse touches non-sterile items. Choice C is incorrect because using a non-sterile glove to touch the sterile field directly introduces contaminants. Choice D is incorrect as touching the edge of the sterile drape with a hand may not necessarily contaminate the entire field, unlike opening it on a wet surface.

5. A nurse on the IV team is conducting an in-service education program about the complications of IV therapy. Which of the following statements by an attendee indicates an understanding of the manifestations of infiltration? (Select all that apply.)

• A. “The temperature around the IV site is cooler.”
• B. “The rate of the infusion increases.”
• C. “The skin at the IV site is red.”
• D. “The IV dressing is damp.”

Correct answer: A

Rationale: The correct statement is: 'The temperature around the IV site is cooler.' Cooler temperature around the site is indicative of infiltration, where IV fluid leaks into the surrounding tissue, causing tissue swelling. The other options are incorrect: B) An increase in infusion rate is not a sign of infiltration; instead, it could indicate an issue with the infusion pump or the IV catheter. C) Redness around the IV site is more indicative of infection rather than infiltration. D) A damp IV dressing is more suggestive of a leak in the IV system, not infiltration.

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