Nursing Elites

1. What action would the nurse take for a 4-year-old child who is called to the operating room for a planned myringotomy?

• A. Removing the child's undergarments
• B. Placing the child's toys on the bedside table
• C. Allowing the child to climb onto the stretcher
• D. Having the parents accompany the child to the operating suite

Correct answer: D

Rationale: The correct action is to have the parents accompany the child to the operating suite. Current practice encourages parents to stay with the child as long as possible to reduce stress related to a frightening experience. Removing the child's undergarments is usually not necessary for a myringotomy procedure. Placing the child's toys on the bedside table is important, especially a favorite one, for comfort until sedation is induced. Allowing the child to climb onto the stretcher may not be safe or appropriate as the child is too young to do so independently.

2. Based on the nursing diagnosis of risk for infection, which intervention is best for the nurse to implement when providing care for an older incontinent client?

• A. Maintain standard precautions.
• B. Initiate contact isolation measures.
• C. Insert an indwelling urinary catheter.
• D. Instruct the client in the use of adult diapers.

Correct answer: A

Rationale: The correct intervention for a nursing diagnosis of risk for infection in an older incontinent client is to maintain standard precautions. The best way to reduce the risk of infection in vulnerable clients is through proper handwashing and adherence to standard precautions. Option B, initiating contact isolation measures, is excessive unless the client has a confirmed infection requiring isolation. Option C, inserting an indwelling urinary catheter, actually increases the risk of infection due to the introduction of a foreign body. Option D, instructing the client in the use of adult diapers, does not directly address the risk of infection and is not as effective as maintaining standard precautions in preventing infection transmission.

3. What is the priority nursing action to assist an anxious father in his concern about not bonding with his newborn?

• A. Encouraging the father to participate in a parenting class
• B. Providing time for the father to be alone with and get to know the baby
• C. Offering the father a demonstration on newborn diapering, feeding, and bathing
• D. Allowing time for the father to ask questions after viewing a film about a new baby

Correct answer: B

Rationale: The priority nursing action to assist an anxious father in his concern about not bonding with his newborn is providing time for the father to be alone with and get to know the baby. Time alone provides the opportunity for paternal-infant attachment and bonding, which can help reduce the father's anxiety. Encouraging the father to participate in a parenting class, although helpful, does not directly address the immediate need for bonding. Offering a demonstration on newborn care tasks like diapering, feeding, and bathing may not effectively address the father's anxiety at that moment, as he may not be ready to absorb such information. Allowing time for the father to ask questions after viewing a film about a new baby is a simplistic approach that may not adequately address the emotional needs and concerns of the father regarding bonding with his newborn.

4. The healthcare provider is aware that malnutrition is a common problem among clients served by a community health clinic for the homeless. Which laboratory value is the most reliable indicator of chronic protein malnutrition?

• A. Low serum albumin level
• B. Low serum transferrin level
• C. High hemoglobin level
• D. High cholesterol level

Correct answer: A

Rationale: Long-term protein deficiency significantly lowers serum albumin levels. Albumin, derived from protein breakdown, is produced by the liver when adequate amino acids are available. Due to its long half-life, acute protein loss minimally affects serum albumin levels. In contrast, serum transferrin, with a shorter half-life of 8 to 10 days, decreases with acute protein deficiency and is not a reliable indicator of chronic protein malnutrition. Elevated hemoglobin levels may occur in conditions like dehydration or chronic obstructive pulmonary disease, making it an unreliable indicator of chronic protein malnutrition. High cholesterol levels are not directly linked to protein malnutrition and do not serve as a reliable indicator. Therefore, the most reliable indicator of chronic protein malnutrition among the options provided is a low serum albumin level.

5. The nurse selects the best site for insertion of an IV catheter in the client's right arm. Which documentation should the nurse use to identify the placement of the IV access?

• A. Left brachial vein
• B. Right cephalic vein
• C. Dorsal side of the right wrist
• D. Right upper extremity

Correct answer: B

Rationale: The correct answer is the right cephalic vein. The cephalic vein is a large and superficial vein commonly used for IV access. Documenting the specific anatomic name of the vein used for IV access, such as the cephalic vein, is essential for accurate medical records. Option A, the left brachial vein, is incorrect as the brachial vein is too deep to be accessed for IV infusion. Option C, the dorsal side of the right wrist, is not a recommended IV access site due to fragile veins and potential pain for the patient. Option D, right upper extremity, is too broad and lacks the specificity necessary for precise documentation of the IV access site.

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