Nursing Elites

1. You are caring for an infant who is just about 12 months old. Which assessment data is normal for the infant at this age?

• A. The infant had doubled their birth weight at twelve months.
• B. The infant had tripled their birth weight at twelve months.
• C. The mother reports that the infant is drinking 60 mLs per kilogram of its body weight.
• D. The infant had grown � inch since last month.

Correct answer: A

Rationale: The normal assessment data for the infant at 12 months of age is that the infant has doubled their birth weight at 12 months of age. The mother's reports that the infant is drinking 60 mLs per kilogram of its body weight and the fact that the infant had grown � inch since last month are not normal assessment data. Infants are fed breast milk or formula every two to four hours with a total daily intake of 80 to 100 mLs per kilogram of body weight. As the neonate grows, they gain five to seven ounces during the first six months and then they double their birth weight during the first year; the head circumference increases a half inch each month for six months and then two tenths of an inch until the infant is one year of age. Similarly, the height or length of the newborn increases an inch a month for the first 6 months and then 1/2 inch a month until the infant is 1 year of age.

2. Which of the following tasks may be delegated to unlicensed assistive personnel?

• A. Cleansing a wound with peroxide
• B. Irrigating a colostomy
• C. Assisting with performing incentive spirometry
• D. Removing a saline-lock IV

Correct answer: C

Rationale: Certain tasks can be safely delegated to unlicensed assistive personnel to assist nurses in their workload. Tasks that involve routine activities like incentive spirometry can be delegated. Unlicensed assistive personnel can assist clients with incentive spirometry, helping in promoting lung expansion and preventing respiratory complications. Cleansing a wound with peroxide (Choice A) and irrigating a colostomy (Choice B) involve more complex procedures that should be performed by licensed healthcare providers due to the risk of infection and potential complications. Removing a saline-lock IV (Choice D) requires specialized training and should only be performed by licensed personnel to prevent complications and ensure patient safety. The nurse remains responsible for delegating tasks appropriately and overseeing the care provided by unlicensed assistive personnel.

3. Mr. K is admitted to the orthopedic unit one morning in preparation for a total knee replacement to start in two hours. Which of the following is a priority topic to instruct this client on admission?

• A. The approximate length of the surgery
• B. The type of anticoagulants that will be prescribed
• C. The time of the next meal of solid food
• D. The length of time until the client can return to work

Correct answer: A

Rationale: The priority topic to instruct a client admitted for a total knee replacement surgery should be the approximate length of the surgery. Pre-surgical teaching should focus on preparing the client for the upcoming procedure. Providing information about the duration of the surgery can help manage the client's expectations, reduce anxiety, and ensure they are mentally prepared for the operation. While details about post-operative care, anticoagulants, meals, and return to work are important, they are not the immediate priority during the preoperative phase. These aspects can be addressed at a later stage in the client's care journey.

4. You are attempting to teach the wife of a Greek patient how to administer his gastrostomy tube feedings once he returns home. She smiles and nods through your explanations, but when you ask her for a return demonstration, she looks confused and shakes her head. Her daughter enters the room and states that she does not speak English. What would be most helpful in this situation?

• A. Teach the daughter instead
• B. Teach both and ask the daughter to translate for you
• C. Contact a home health agency to provide care
• D. Provide a pamphlet with detailed instructions

Correct answer: B

Rationale: Teaching both the patient's wife and the daughter is the best option in this situation. The daughter may not always be available, and the wife is eager to care for her husband at home. While a hospital interpreter is often preferred, asking the daughter to interpret is a good alternative. This approach allows the daughter to receive instruction and reinforce it for herself as she translates it to her mother. Contacting a home health agency may not be necessary if family members are willing and able to assist. Providing a pamphlet with detailed instructions would not be as effective in ensuring the wife fully understands the procedure and can carry it out correctly.

5. A client is found lying on the floor near the bathroom door, stating, 'I thought I could get up on my own.' What information must the nurse document in this situation?

• A. A statement explaining the condition the client was found in, quoting the client's words about the situation
• B. An explanation of how the fall happened and when the physician was notified
• C. An account of the conditions of the room that contributed to the client's fall
• D. A summary of the client's medical history and current medications

Correct answer: A

Rationale: When a fall or injury occurs while under nursing care, it is crucial to document the known aspects of the situation and the response to the injury. In this scenario, the nurse should document the client's condition as found and quote the client's own words about the situation. This helps provide a clear account of the event without implying blame. Options B, C, and D are incorrect because detailing how the fall happened, listing room conditions, or summarizing medical history are not directly relevant to documenting the immediate situation and the client's own words following the fall.

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