Nursing Elites

1. The nurse is teaching a client about sleep and gives background information on normal sleep patterns. Which of the following substances promotes sleep?

• A. serotonin
• B. cortisol
• C. alcohol
• D. narcotics

Correct answer: A

Rationale: Serotonin is a substance found in the body that promotes sleep. It plays a role in the synthesis of a hypnogenic factor that directly induces sleep. Cortisol is a stress hormone that can disrupt sleep patterns. Alcohol can disrupt REM sleep and negatively impact sleep quality. Narcotics, like alcohol, can interfere with sleep architecture and lead to poor quality sleep. Therefore, the correct answer is serotonin as it is associated with promoting sleep, while the other substances listed can have negative effects on sleep patterns.

2. When a client needs oxygen therapy, what is the highest flow rate that oxygen can be delivered via nasal cannula?

• A. 2 liters/minute
• B. 4 liters/minute
• C. 6 liters/minute
• D. 8 liters/minute

Correct answer: C

Rationale: The correct answer is 6 liters/minute. When a client requires oxygen therapy, the maximum flow rate that oxygen can be delivered via nasal cannula is 6 liters/minute. Nasal cannula can effectively deliver oxygen up to 6 liters/minute. Flow rates exceeding 6 liters/minute may lead to drying of the nasal passages and discomfort for the client. Higher flow rates, like 8 liters/minute, should be administered using a mask to ensure sufficient oxygenation. Options A, B, and D are incorrect as they indicate flow rates that surpass the recommended maximum for nasal cannula delivery.

3. A new mother asks the nurse, 'I was told that my infant received my antibodies during pregnancy. Does that mean that my infant is protected against infections?' Which statement should the nurse make in response to the mother?

• A. The immune system of an infant is immature, and the infant is at risk for infection.
• B. The transfer of your antibodies protects your infant until the infant is 12 months old.
• C. Yes, your infant is protected from all infections.
• D. If you breastfeed, your infant is protected from infection.

Correct answer: A

Rationale: The transplacental transfer of maternal antibodies supplements the infant's weak response to infection until approximately 3 to 4 months of age. While the infant starts producing immunoglobulin (Ig) soon after birth, it only reaches about 60% of the adult IgG level, 75% of the adult IgM level, and 20% of the adult IgA level by 1 year of age. Breast milk provides additional IgA protection. Although the immune system matures during infancy, full protection against infections is not achieved until early childhood, putting the infant at risk for infections. Choice B is incorrect because maternal antibody protection typically lasts around 3 to 4 months, not until the infant is 12 months old. Choice C is incorrect as infants are not shielded from all infections due to their immature immune system. Choice D is incorrect because while breastfeeding offers extra protection, it does not guarantee complete immunity against infections.

4. The mother of a child who weighs 45 lb asks a nurse about car safety seats. The nurse tells the mother to place the child in which car safety seat?

• A. Car safety seat in the back seat in a face-forward position
• B. Booster seat with one of the car's seat belts placed over the child
• C. Booster seat in a rear-facing position in the front seat
• D. Car safety seat in a face-forward position in the front seat

Correct answer: B

Rationale: The correct answer is to place the child in a booster seat with one of the car's seat belts placed over the child. A child needs to remain in a car safety seat until he or she weighs 40 lb. Once the child has outgrown the car safety seat, a booster seat is used. Booster seats are designed to raise the child high enough so that the restraining straps are correctly positioned over the child's chest and pelvis, providing optimal safety. Placing a child in a booster seat in a rear-facing position in the front seat is incorrect as children should not be seated in the front seat due to potential airbag-related injuries. Additionally, car safety seats are used for children weighing less than 40 lb and are placed in the middle of the back seat in a rear-facing position for maximum protection.

5. The nurse is preparing to administer the 9 am dose of IV antibiotics when she notes the IVAC cord is frayed with wiring visible. What action should be her priority for this client?

• A. Notify maintenance to come and check the pump immediately.
• B. Continue with the administration of the antibiotic and fill out an equipment maintenance request.
• C. Immediately discontinue the use of this IVAC pump and obtain a replacement.
• D. Tag the equipment for maintenance.

Correct answer: C

Rationale: The correct action is to immediately discontinue the use of the IVAC pump and obtain a replacement because the frayed cord poses a safety risk to the client. Continuing to use the pump with visible wiring could lead to electric shock or other serious harm to the client. Notifying maintenance to come and check the pump immediately (Choice A) may cause unnecessary delays in ensuring the client's safety. Continuing with the administration of the antibiotic and filling out an equipment maintenance request (Choice B) is unsafe as it ignores the immediate danger. Tagging the equipment for maintenance (Choice D) does not address the urgent need to protect the client from harm.

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