Nursing Elites

1. A guideline that is utilized in determining priorities is to assess the status of the following, EXCEPT:

• A. perfusion
• B. locomotion
• C. respiration
• D. mentation

Correct answer: D

Rationale: When determining priorities in patient care, assessing perfusion, respiration, and locomotion are crucial. However, assessing mentation is also important but not typically included in the ABCs of emergency care. Monitoring mentation is essential for neurological assessment and detecting changes in mental status, but it is not part of the immediate priorities in life-threatening situations.

2. A nurse is assessing a client who reports muscle spasms in his calves and tingling in his hands. The client indicates consuming a low intake of milk products and green leafy vegetables. The nurse should identify that the client's findings indicate a deficiency in which of the following sources of nutrition?

• A. Iron
• B. Omega-3 fatty acids
• C. Vitamin C
• D. Calcium

Correct answer: D

Rationale: The correct answer is D, Calcium. Muscle spasms and tingling suggest a calcium deficiency, which is commonly associated with a low intake of milk products and green leafy vegetables. Iron (choice A) deficiency typically presents with fatigue and weakness, not muscle spasms and tingling. Omega-3 fatty acids (choice B) are essential for brain function and heart health, but their deficiency does not manifest as muscle spasms and tingling. Vitamin C (choice C) deficiency leads to scurvy with symptoms like bleeding gums and bruising, not muscle spasms and tingling.

3. Which hormone is produced in fat tissue and helps regulate body fat by suppressing appetite?

• A. glucagon
• B. ghrelin
• C. leptin
• D. insulin

Correct answer: C

Rationale: The correct answer is C, leptin. Leptin is a hormone produced by fat cells that helps regulate energy balance by suppressing hunger, thus aiding in the regulation of body fat. Glucagon (choice A) is a hormone that raises blood glucose levels, ghrelin (choice B) stimulates appetite, and insulin (choice D) regulates blood sugar levels and promotes glucose uptake.

4. What is considered fast breathing in a 13-month-old child if the respiratory rate (RR) exceeds which value?

• A. 40 breaths per minute
• B. 50 breaths per minute
• C. 60 breaths per minute
• D. 30 breaths per minute

Correct answer: C

Rationale: In the context of pediatric care, a respiratory rate of more than 60 breaths per minute in a child aged 13 months is considered fast breathing, hence option 'C' is correct. Options 'A', 'B', and 'D' are incorrect as they do not meet the specified criteria for fast breathing in a 13-month-old. Effective nursing care involves comprehensive assessments that address all aspects of a patient's condition, including monitoring respiratory rates, to ensure that interventions are appropriately targeted and outcomes are optimized.

5. Baby John develops hyperbilirubinemia. What is a method used to treat hyperbilirubinemia in a newborn?

• A. Keeping infants in a warm and dark environment
• B. Administration of cardiovascular stimulant
• C. Gentle exercise to stop muscle breakdown
• D. Early feeding to speed passage of meconium

Correct answer: A

Rationale: Patient safety and efficacy of care depend on actions rooted in established nursing protocols that consider both the immediate and long-term needs of the patient.

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