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. What action should the nurse take if she observes an unlicensed assistive personnel (UAP) soaking a client's foot in a basin of warm water placed on the bed during a total bed bath for a confused and lethargic client?

• A. Remove the basin of water from the client's bed immediately
• B. Remind the UAP to dry between the client's toes completely
• C. Advise the UAP that this procedure may damage the skin
• D. Add skin cream to the basin of water while the foot is soaking

Correct answer: A

Rationale: The correct action for the nurse to take is to remove the basin of water from the client's bed immediately. Soaking a client's foot in a basin of water placed on the bed can lead to spills, create infection risks, and is not a safe practice. It is essential to prioritize the safety and well-being of the client by ensuring a safe environment during care procedures. Choices B, C, and D are incorrect as they do not address the immediate risk associated with the situation. Reminding the UAP to dry between the client's toes, advising about potential skin damage, or adding skin cream do not mitigate the immediate hazards of having a basin of water on the bed.

3. A client is incontinent of loose stool and is reporting a painful perineum. Which of the following is the priority nursing action?

• A. Assess the client's perineum
• B. Administer pain medication
• C. Clean the area with a mild cleanser
• D. Apply a barrier cream to the affected area

Correct answer: A

Rationale: Assessing the client's perineum is the priority nursing action in this situation. By checking the perineum, the nurse can evaluate for skin damage, irritation, infection, or other issues that may be causing the client's pain. This assessment is crucial to determine the appropriate interventions needed to address the client's discomfort and prevent complications. Administering pain medication, cleaning the area with a mild cleanser, or applying a barrier cream are important interventions but should follow the initial assessment of the perineum to ensure comprehensive care and effective management of the client's condition. Prioritizing assessment allows for a targeted and individualized approach to care, enhancing the client's overall well-being.

4. The LPN observes an unlicensed assistive personnel (UAP) taking a client's blood pressure with a cuff that is too small, but the blood pressure reading obtained is within the client's usual range. What action is most important for the nurse to implement?

• A. Tell the UAP to use a larger cuff at the next scheduled assessment.
• B. Reassess the client's blood pressure using a larger cuff.
• C. Have the unit educator review this procedure with the UAPs.
• D. Teach the UAP the correct technique for assessing blood pressure.

Correct answer: B

Rationale: Reassessing the client's blood pressure using a larger cuff is the most important action for the nurse to implement in this situation. Using the correct cuff size is crucial for obtaining accurate blood pressure readings. By reassessing with a larger cuff, the nurse can ensure an accurate measurement and proper monitoring of the client's blood pressure. Choice A is not the best option as it doesn't address the immediate need for accurate blood pressure measurement. Choice C is not the most appropriate action at this time since the immediate concern is ensuring correct blood pressure assessment. Choice D, while important, is not the most critical step in this scenario where immediate reassessment is needed with the correct cuff size.

5. A nurse is planning care for a client who reports abdominal pain. An assessment by the nurse reveals the client has a temperature of 39.2 degrees C (102 degrees F), heart rate of 105/min, a soft tender abdomen, and census overdue by 2 days. Which of the following findings should be the nurse's priority?

• A. Temperature
• B. Heart rate
• C. Abdominal tenderness
• D. Census overdue

Correct answer: A

Rationale: The correct answer is A: Temperature. A high fever is a significant indicator of infection or other serious conditions, making it the priority finding. Elevated temperature indicates an immediate concern for infection, which can quickly escalate and lead to severe complications if not addressed promptly. While heart rate, abdominal tenderness, and census overdue are important aspects to consider in the client's care, addressing the fever takes precedence due to its potential severity and implications for the client's health.

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