Nursing Elites

1. During the check-up of a 2-month-old infant at a well-baby clinic, the mother expresses concern to the nurse because a flat pink birthmark on the baby's forehead and eyelid has not gone away. What is an appropriate response by the nurse?

• A. Mongolian spots are a normal finding in dark-skinned infants.
• B. Port wine stains are typically associated with other malformations.
• C. Telangiectatic nevi are normal and will disappear as the baby grows.
• D. The child is too young for surgical removal of these at this time.

Correct answer: C

Rationale: The correct answer is C. Telangiectatic nevi, often referred to as 'stork bites,' are common birthmarks in infants and are considered normal. These birthmarks usually fade and disappear as the child grows older. Choices A, B, and D are incorrect because Mongolian spots are bluish-gray birthmarks commonly found in darker-skinned infants, port wine stains are vascular birthmarks that typically do not disappear, and surgical removal is not recommended for telangiectatic nevi as they usually resolve on their own.

2. An adult client is found to be unresponsive on morning rounds. After checking for responsiveness and calling for help, the next action that should be taken by the nurse is to:

• A. Check the carotid pulse
• B. Deliver 5 abdominal thrusts
• C. Give 2 rescue breaths
• D. Open the client's airway

Correct answer: D

Rationale: In this scenario, the priority is to ensure the client has a clear airway to facilitate breathing. After verifying unresponsiveness and calling for help, the nurse should open the client's airway to aid in maintaining ventilation. Checking the carotid pulse (Choice A) may be important but comes after ensuring a clear airway. Delivering abdominal thrusts (Choice B) is indicated for choking, not for an unresponsive client. Giving rescue breaths (Choice C) is also important but only after the airway has been established.

3. During a physical assessment, a nurse is assessing 4 adult clients. Which of the following physical assessment techniques should the nurse use?

• A. Ensure the bladder of the BP cuff surrounds 80% of their arm.
• B. Use the BP cuff on the forearm if the upper arm is not accessible.
• C. Apply the BP cuff loosely around the arm.
• D. Use a pediatric cuff for adults with small arms.

Correct answer: A

Rationale: The correct answer is to ensure the bladder of the BP cuff surrounds 80% of the arm. This technique is crucial for obtaining accurate blood pressure readings. Choice B is incorrect because using the BP cuff on the forearm may lead to inaccurate readings. Choice C is incorrect as applying the BP cuff loosely can also result in inaccurate measurements. Choice D is incorrect because using a pediatric cuff for adults with small arms would not provide accurate blood pressure readings.

4. The healthcare provider is caring for a 17-month-old with acetaminophen poisoning. Which lab reports should the healthcare provider review first?

• A. Prothrombin time (PT) and partial thromboplastin time (PTT)
• B. Red blood cell and white blood cell counts
• C. Blood urea nitrogen and creatinine levels
• D. Liver enzymes (AST and ALT)

Correct answer: D

Rationale: In acetaminophen poisoning, liver damage is a significant concern due to the toxic effects of the drug on the liver. Liver enzymes such as AST (aspartate aminotransferase) and ALT (alanine aminotransferase) are essential markers to assess liver function and damage. Monitoring these enzymes early is crucial to detect hepatotoxicity and guide further management. Prothrombin time and partial thromboplastin time are coagulation studies and are not the priority in acetaminophen poisoning. Red and white blood cell counts are not specific to assess liver damage in this context. Blood urea nitrogen and creatinine levels are primarily used to evaluate kidney function, which is not the primary concern in acetaminophen poisoning.

5. The nurse is caring for a patient diagnosed with diabetes. Which task will the nurse assign to the nursing assistive personnel?

• A. Providing nail care
• B. Teaching foot care
• C. Making the patient's bed
• D. Determining aspiration risk

Correct answer: C

Rationale: The correct answer is making the patient's bed. Delegating bed-making tasks to nursing assistive personnel is appropriate as it falls within their scope of practice and helps free up the nurse's time to focus on tasks that require their specialized skills and knowledge. Providing nail care and teaching foot care involve direct patient care and education, which should be performed by licensed nursing staff. Determining aspiration risk requires critical thinking and clinical judgment, making it a responsibility of the nurse.

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