Nursing Elites

1. The mother of a child who weighs 45 lb asks a nurse about car safety seats. The nurse tells the mother to place the child in which car safety seat?

• A. Car safety seat in the back seat in a face-forward position
• B. Booster seat with one of the car's seat belts placed over the child
• C. Booster seat in a rear-facing position in the front seat
• D. Car safety seat in a face-forward position in the front seat

Correct answer: B

Rationale: The correct answer is to place the child in a booster seat with one of the car's seat belts placed over the child. A child needs to remain in a car safety seat until he or she weighs 40 lb. Once the child has outgrown the car safety seat, a booster seat is used. Booster seats are designed to raise the child high enough so that the restraining straps are correctly positioned over the child's chest and pelvis, providing optimal safety. Placing a child in a booster seat in a rear-facing position in the front seat is incorrect as children should not be seated in the front seat due to potential airbag-related injuries. Additionally, car safety seats are used for children weighing less than 40 lb and are placed in the middle of the back seat in a rear-facing position for maximum protection.

2. The client is being taught about the use of Rifampin for prophylaxis following exposure to meningitis. What change in bodily functions should the client be informed about?

• A. The client's urine may turn blue.
• B. The client remains infectious to others for 48 hours.
• C. The client's contact lenses may be stained orange.
• D. The client's skin may take on a crimson glow.

Correct answer: C

Rationale: Rifampin has the unusual effect of turning body fluids an orange color. Soft contact lenses might become permanently stained. Clients should be taught about these side effects to avoid unnecessary concern. Option A is incorrect as Rifampin does not cause the urine to turn blue. Option B is incorrect as the client is not infectious to others due to taking Rifampin for prophylaxis. Option D is incorrect as Rifampin does not cause the skin to take on a crimson glow.

3. A 10-year-old boy has been diagnosed with a congenital heart defect. Which of the following clinical signs does not indicate CHF?

• A. Increased body weight
• B. Elevated heart rate
• C. Lower extremity edema
• D. Compulsive behavior

Correct answer: D

Rationale: Compulsive behavior is not a clinical sign typically associated with congestive heart failure (CHF). CHF commonly presents with symptoms such as increased body weight due to fluid retention, elevated heart rate as the heart works harder to pump blood effectively, and lower extremity edema caused by fluid buildup. While behavioral changes can occur in response to illness, compulsive behavior is not a typical indicator of CHF. Choices A, B, and C are more commonly linked to CHF and should be monitored in patients with this condition.

4. Which of the following is not an advanced directive?

• A. informed consent
• B. living will
• C. durable power of attorney for health care
• D. health care proxy

Correct answer: A

Rationale: Informed consent is the process of obtaining permission from a patient before conducting a healthcare intervention. It is not considered an advanced directive. A living will is a legal document that outlines a person's preferences for medical treatment if they are unable to communicate. A durable power of attorney for health care designates a person to make medical decisions on behalf of the patient. A health care proxy, which is another term for a durable power of attorney for health care, also involves appointing someone to make healthcare decisions for an individual if they become unable to do so. Therefore, the correct answer is 'informed consent,' as it is not an advanced directive but rather a different aspect of patient care.

5. A nurse and a nursing assistant enter a client's room to provide care and find the client lying on the floor. Which action should the nurse take first?

• A. Ask the nursing assistant to complete an incident report
• B. Check the client's level of consciousness and vital signs
• C. Contact the unit secretary on the intercom and ask that the client's health care provider be called
• D. Ask the nursing assistant to assist in getting the client back to bed

Correct answer: B

Rationale: When a client sustains a fall, the nurse must first assess the client. The nurse should check the client's level of consciousness and vital signs to determine the severity of the situation and provide appropriate care promptly. This immediate assessment is crucial in ensuring the client's immediate needs are addressed. Asking the nursing assistant to complete an incident report (choice A) is not the priority as the client's condition needs immediate attention. Contacting the unit secretary to call the client's health care provider (choice C) can be done after the initial assessment has been completed. Asking the nursing assistant to assist in getting the client back to bed (choice D) should only be considered after ensuring the client is stable and safe to move.

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