Nursing Elites

1. The nurse has completed client teaching about introducing solid foods to an infant. To evaluate teaching, the nurse asks the mother to identify an appropriate first solid food. Which of the following is an appropriate response?

• A. pureed canned squash
• B. pureed apples
• C. yogurt
• D. infant rice cereal

Correct answer: D

Rationale: The correct answer is infant rice cereal. Single-grain infant cereals are recommended as the first solid food because they are easily digestible and have added iron content. Choice C, yogurt, is incorrect because yogurt is a milk product and should be delayed until the child is 12 months old due to the risk of milk allergy. Choices A and B are incorrect because fruits and vegetables are typically introduced after cereals to help the infant get accustomed to solid foods gradually.

2. A nurse in a medical-surgical unit overhears the nursing staff openly discussing a client and stating that the client is uncooperative and a real pain to care for. The nurse would most appropriately manage this issue by taking which action?

• A. Leaving articles about judgmental opinions in the nurses' report room
• B. Reporting the nurses' comments to administration
• C. Discouraging the judgmental comments
• D. Ignoring the comments made about the client

Correct answer: C

Rationale: Nurses must discuss clients in a professional manner and avoid using judgmental language such as 'uncooperative' or 'difficult.' When such comments and language are discouraged, fewer comments will be made. Ignoring the comments is an inappropriate option because the concern will not be addressed. Leaving articles about judgmental opinions in the nurses' report room indirectly addresses the issue, but there is no guarantee that the staff will read them. Reporting the nurses' comments to administration does not directly address the issue. The best approach for the nurse is to discourage judgmental comments directly with the staff members. Since this action is not provided in the options, discouraging judgmental comments is the most appropriate way to manage this concern.

3. A client is having a seizure; his blood oxygen saturation drops from 92% to 82%. What should the nurse do first?

• A. Open the airway.
• B. Administer oxygen.
• C. Suction the client.
• D. Check for breathing.

Correct answer: A

Rationale: When a client is having a seizure and their blood oxygen saturation drops significantly, the priority action for the nurse is to open the airway. This allows for adequate oxygenation and ventilation. Administering oxygen can come after ensuring the airway is clear. Suctioning the client should be done if there is an airway obstruction, and checking for breathing is part of the assessment but opening the airway takes precedence to ensure proper oxygenation and ventilation during a critical event like a seizure.

4. All of the following interventions should be performed when fetal heart monitoring indicates fetal distress except:

• A. increase maternal fluids
• B. administer oxygen
• C. decrease maternal fluids
• D. turn the mother

Correct answer: C

Rationale: When fetal distress is indicated, interventions are aimed at improving oxygenation and blood flow to the fetus. Increasing maternal fluids helps improve blood flow and oxygen delivery, administering oxygen increases oxygenation levels, and turning the mother can help optimize fetal oxygenation. Decreasing maternal fluids would negatively impact blood volume and can worsen fetal distress, making it the exception among the listed interventions. Therefore, decreasing maternal fluids should not be performed when fetal distress is present.

5. The method of splinting is always dictated by:

• A. location of the injury and whether it is open or closed.
• B. the severity of the client's condition and the priority decision.
• C. the number of available rescuers and the type of splints.
• D. all of the above.

Correct answer: B

Rationale: The correct answer is 'the severity of the client's condition and the priority decision.' When determining the method of splinting, it is crucial to consider the severity of the client's condition and make decisions based on their priority. Choice A is incorrect because while the location of the injury and whether it is open or closed are important factors, they do not always dictate the method of splinting. Choice C is incorrect as the number of available rescuers and the type of splints may impact the execution of splinting but do not solely dictate the method. Choice D is incorrect as it suggests that all the factors mentioned dictate the method, but in reality, the severity of the client's condition and the priority decision are the primary factors.

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