Nursing Elites

1. During a routine office visit, which of the following developmental milestones should the nurse screen for in a 6-month-old child?

• A. standing while holding something
• B. rolling over
• C. sitting up
• D. creeping

Correct answer: B

Rationale: The correct developmental milestone for a 6-month-old child that should be screened during a routine office visit is rolling over. At this age, infants typically start rolling over from their stomach to their back and vice versa. Sitting up usually occurs between 7 and 8 months, creeping between 9 and 10 months, and standing while holding something between 8 and 10 months. Therefore, choices A, C, and D are developmentally appropriate but not typically expected at 6 months of age.

2. A nurse monitoring a newborn infant notes that the infant's respirations are 40 breaths/min. On the basis of this finding, what is the most appropriate action for the nurse to take?

• A. Contacting the registered nurse
• B. Documenting the findings
• C. Wrapping an extra blanket around the infant
• D. Placing the infant in an oxygen tent

Correct answer: B

Rationale: The normal respiratory rate of a newborn infant is 30 to 60 breaths/min, with an average of 40. Since the infant's respiratory rate falls within the normal range, the most appropriate action for the nurse is to document the findings. Contacting the registered nurse, placing the infant in an oxygen tent, or wrapping an extra blanket around the infant are unnecessary actions as the respiratory rate is normal. Documenting the findings is important to provide a record of the assessment and serve as a baseline for future comparisons if needed.

3. Which of the following foods is a complete protein?

• A. corn
• B. eggs
• C. peanuts
• D. sunflower seeds

Correct answer: B

Rationale: Eggs are considered a complete protein because they contain all nine essential amino acids required by the human body. In contrast, corn, peanuts, and sunflower seeds are incomplete proteins as they lack one or more essential amino acids. Corn, although a staple food for many cultures, is deficient in the amino acids lysine and tryptophan. Peanuts are low in the amino acid methionine, and sunflower seeds are low in lysine. Therefore, eggs are the correct answer as a complete protein source.

4. A healthcare professional reviewing a client's record notes documentation that the client has melena. How does the healthcare professional detect the presence of melena?

• A. By checking the client's urine for blood
• B. By checking the client's stool for blood
• C. By checking the client's urine for a decrease in output
• D. By checking the client's bowel movements for diarrhea

Correct answer: B

Rationale: Melena' is the term used to describe abnormal black tarry stool that has a distinctive odor and contains digested blood. It usually results from bleeding in the upper gastrointestinal tract and is often a sign of peptic ulcer disease or small bowel disease. The presence of melena is detected by checking the client's stool for blood. Blood in the client's urine, decreased urine output, and diarrhea are not associated with the assessment for melena.

5. The LPN is taking care of a client with a documented allergy to Penicillin. After rounds, the LPN notices that the client has an order for Cefazolin. Which of the following actions would be the least appropriate?

• A. The LPN clarifies the severity of the Penicillin allergy.
• B. The LPN discusses the order with the care team prior to administering Cefazolin.
• C. The LPN administers all ordered medications except for the Cefazolin.
• D. The LPN monitors the client after a test dose of Cefazolin is administered.

Correct answer: C

Rationale: The least appropriate action is for the LPN to administer all ordered medications except for the Cefazolin. The LPN should always consider the client's documented allergy to Penicillin seriously. It is crucial to discuss the order with the care team before administering Cefazolin to ensure patient safety. Administering a medication that could potentially cause harm due to a documented allergy is unsafe practice. While monitoring the client after a test dose of Cefazolin is important, it should not precede clarification with the care team regarding the allergy and the appropriateness of the medication. Therefore, withholding the Cefazolin is the most appropriate action in this scenario.

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