Nursing Elites

1. During a report from an ER nurse about a client, the nurse identifies a statement that requires additional follow-up. Which of the following statements needs further clarification?

• A. "The client said they have been taking aspirin, but I'm not sure for how long or how much."?
• B. "The client frequently takes antacids, but they have not taken any in the last three days."?
• C. "The client stopped taking ibuprofen after developing gastric ulcers."?
• D. "The client takes Antabuse and has stopped using mouthwash."?

Correct answer: A

Rationale: The correct answer requires further follow-up as the nurse needs to know the duration and dosage of aspirin since it can impact the patient's bleeding risk. Choice B does not require immediate follow-up as not taking antacids for three days is not critical. Choice C indicates a necessary decision made by the client to stop ibuprofen after developing gastric ulcers, hence no immediate follow-up is needed. Choice D provides important information, but the priority is to address the lack of specificity regarding the client's aspirin use, which is crucial for assessing bleeding risk and potential interactions.

2. A nurse is assisting with data collection on the language development of a 9-month-old infant. Which developmental milestone does the nurse expect to note in an infant of this age?

• A. The infant babbles single consonants
• B. The infant babbles
• C. The infant says 'Mama.'
• D. The infant says 'Mama.'

Correct answer: D

Rationale: An 8- to 9-month-old infant can string vowels and consonants together. The first words, such as 'Mama,' 'Daddy,' 'bye-bye,' and 'baby,' begin to have meaning. A 1- to 3-month-old infant produces cooing sounds. Babbling is common in a 3- to 4-month-old. Single-consonant babbling occurs between 6 and 8 months of age. Therefore, the milestone of the infant saying 'Mama' is the most appropriate for a 9-month-old, indicating early language development. The other choices are developmentally inaccurate for a 9-month-old infant.

3. A nurse calculates a newborn infant's Apgar score 1 minute after birth and determines that the score is 6. What is the most appropriate action for the nurse to take?

• A. Initiate cardiopulmonary resuscitation
• B. Gently stimulate the infant by rubbing his back while administering oxygen
• C. Recheck the score in 5 minutes
• D. Provide no action except to support the infant's spontaneous efforts

Correct answer: B

Rationale: The Apgar score is a method for rapidly evaluating an infant's cardiorespiratory adaptation after birth. The nurse assigns scores in five areas: heart rate, respiratory effort, muscle tone, reflex response, and color, totaling the scores. A score of 8 to 10 requires no action other than supporting the infant's spontaneous efforts and observation. A score of 4 to 7 indicates the need to gently stimulate the infant by rubbing his back while administering oxygen. If the score is 1 to 3, the infant requires resuscitation. Therefore, in this scenario with an Apgar score of 6, the correct action is to gently stimulate the infant by rubbing his back while administering oxygen. Initiating cardiopulmonary resuscitation would be excessive at this point, and rechecking the score in 5 minutes may delay necessary interventions. Providing no action except to support the infant's spontaneous efforts is insufficient for a score of 6, indicating the need for stimulation and oxygen administration.

4. The teaching plan for a postpartum client who is about to be discharged should include which of the following instructions?

• A. "It is normal for your breasts to be tender. You should call the physician if you also have redness and fatigue."?
• B. "Because your baby was delivered vaginally, you might have to urinate more frequently."?
• C. "It is normal to run a low-grade temperature for a few days. If it is higher than 100�F, call your physician."?
• D. "Be sure to call your physician if your vaginal discharge becomes bright red."?

Correct answer: D

Rationale: The correct answer is to instruct the postpartum client to call the physician if their vaginal discharge becomes bright red. The vaginal discharge after birth is called lochia, and a return to red or containing clots could indicate impending hemorrhage or infection, necessitating notification of the physician. Choice A is incorrect because although some tenderness may be expected, redness and fatigue are clinical manifestations of mastitis, not normal postpartum changes. Choice B is also incorrect as increased frequency of urination after vaginal delivery could indicate a urinary tract infection, not a normal postpartum change. Choice C is incorrect because running a low-grade temperature for a few days is not expected postpartum; an elevated temperature above 100�F should be reported to the physician as it could indicate infection.

5. An appraisal of self-care practices involves an assessment of:

• A. all diagnostic tests.
• B. home treatment practices, including nurse visits for the sick or disabled.
• C. the family's capability to get health insurance.
• D. caregiving needs and the potential for strain.

Correct answer: D

Rationale: An appraisal of self-care practices focuses on assessing caregiving needs and the potential for strain. This involves evaluating the support system in place for individuals requiring care, the level of strain experienced by caregivers, and the overall impact of caregiving responsibilities on both the caregiver and the care recipient. The other options presented do not directly relate to the assessment of self-care practices. Diagnostic tests, home treatment practices, and the family's capability to obtain health insurance are important aspects of healthcare but do not specifically pertain to the evaluation of self-care practices.

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