Nursing Elites

1. What are the fine, down-like hairs on the newborn's ears, shoulders, lower back, and/or forehead known as?

• A. Vernix.
• B. Lanugo.
• C. Milia.
• D. Vibrissae.

Correct answer: B

Rationale: Lanugo is the term used to describe the fine, down-like hairs found on a newborn's ears, shoulders, lower back, and/or forehead. These hairs are different from vernix, which is a waxy or cheese-like white substance covering the skin of newborns. Milia are small, white, or yellowish cysts that commonly appear on a newborn's face, while vibrissae are the thick, stiff hairs commonly found around the nose and other parts of the face.

2. A charge nurse making rounds observes that an assistive personnel (AP) has applied wrist restraints to a client who is agitated and does not have a prescription for restraints. Which of the following actions should the nurse take first?

• A. Remove the restraints from the client's wrists
• B. Review the chart for nonrestraint alternatives for agitation
• C. Speak with the AP about the incident
• D. Inform the unit manager of the incident

Correct answer: A

Rationale: The correct action for the nurse to take first is to remove the restraints from the client's wrists. Restraints should not be applied without a prescription due to the risk of harm to the client. Removing the restraints promptly is a priority to ensure the client's safety. Reviewing nonrestraint alternatives, speaking with the AP, and informing the unit manager can follow after ensuring the client's immediate safety by removing the restraints.

3. A charge nurse is making staff assignments on a medical-surgical unit. Which of the following tasks should the nurse plan to delegate to an assistive personnel?

• A. Measuring oxygen saturation for a client who has dyspnea
• B. Inserting a rectal suppository for a client who is vomiting
• C. Performing nasal hygiene for a client who has an NG tube
• D. Pouching a client's ostomy bag for a new colostomy

Correct answer: D

Rationale: Pouching a new colostomy is a task that can be safely and appropriately delegated to an assistive personnel as it falls within their scope of practice. Measuring oxygen saturation (Choice A) requires a higher level of training and assessment, making it unsuitable for delegation. Inserting a rectal suppository (Choice B) and performing nasal hygiene (Choice C) involve invasive procedures that are typically performed by licensed nursing staff due to the associated risks and complexities, making them inappropriate for delegation to assistive personnel.

4. A client diagnosed with type 1 diabetes receives insulin. He asks the nurse why he can't just take pills instead. What is the best response by the nurse?

• A. Insulin must be injected because it needs to work quickly.
• B. Insulin can't be in a pill because it is destroyed in stomach acid.
• C. Have you talked to your doctor about taking pills instead?
• D. I know it is tough, but you will get used to the shots soon.

Correct answer: B

Rationale: The correct answer is B because insulin cannot be taken orally as it gets destroyed by stomach acid. Choice A is incorrect as the speed of action is not the reason why insulin can't be in pill form. Choice C is incorrect as it doesn't address the nature of insulin. Choice D is incorrect as it doesn't provide a factual reason why insulin can't be in pill form.

5. You are working on a pediatric unit. Which toy or other diversional item or activity is most appropriate for your 18-month-old patient?

• A. Story books
• B. Beach balls
• C. An interactive play session with other children less than 2 years of age
• D. Pickup sticks

Correct answer: B

Rationale: A beach ball is appropriate for an 18-month-old as it is safe and can help with motor skills development. Choice A, storybooks, may not be suitable for this age group due to limited attention span. Choice C involves interaction with other children which may not always be feasible in a healthcare setting. Choice D, pickup sticks, poses a choking hazard and is not suitable for toddlers.

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