Nursing Elites

1. A mother who has never breastfed a child before is having trouble getting the baby to latch on to the breast. The baby has lost 3% of its birth weight within the first 2 days of life. The best statement is:

• A. The baby will eventually take to the breast.
• B. I can prepare a bottle if you want to try that.
• C. A small amount of weight loss in the first few days is normal.
• D. I can arrange for the charge nurse to come and talk to you about breastfeeding.

Correct answer: C

Rationale: The correct answer is 'A small amount of weight loss in the first few days is normal.' It is important to reassure the mother that a small amount of weight loss, such as 5-10% of birth weight, in the first few days of life is considered normal for newborns. This reassurance helps alleviate the mother's concerns. Option A is incorrect because it does not address the concern about weight loss; it focuses more on the baby eventually latching on. Option B is not recommended as the first solution for breastfeeding issues, as introducing a bottle early on may lead to nipple confusion. Option D involves escalating the situation to the charge nurse when it can be addressed by providing appropriate information and support directly, making it less necessary in this scenario where reassurance and education are key.

2. In the Emergency Department (ED), which client should the nurse see first?

• A. COPD client with a non-productive cough
• B. Diabetic client who has an infected sore on the foot
• C. Client with adrenal insufficiency who feels weak
• D. Client with a fracture of the forearm in an air splint

Correct answer: C

Rationale: In the Emergency Department, the priority is to assess and manage clients based on the urgency of their conditions. A client with adrenal insufficiency presenting with weakness should be seen first as this could indicate a state of shock, which requires immediate attention to stabilize the client's condition. Weakness in adrenal insufficiency can progress rapidly to a life-threatening adrenal crisis. Choice A, a COPD client with a non-productive cough, may need treatment but is not immediately life-threatening. Choice B, a diabetic client with an infected sore on the foot, requires timely care to prevent complications but can generally wait for evaluation compared to the potential urgency of adrenal insufficiency. Choice D, a client with a fracture of the forearm in an air splint, is important but not as time-sensitive as a client potentially in shock.

3. A client was involved in a motor vehicle accident in which the seat belt was not worn. The client is exhibiting crepitus, decreased breath sounds on the left, complains of shortness of breath, and has a respiratory rate of 34/min. Which of the following assessment findings should concern the nurse the most?

• A. temperature of 102�F and a productive cough
• B. arterial blood gases (ABGs) with a PaO2 of 92 mmHg and PaCO2 of 40 mmHg
• C. trachea deviating to the right
• D. barrel-chested appearance

Correct answer: C

Rationale: The correct answer is 'trachea deviating to the right.' A mediastinal shift is indicative of a tension pneumothorax, which is a dangerous complication seen in trauma patients with symptoms like crepitus, decreased breath sounds, shortness of breath, and tachypnea. Assessing for acute traumatic injuries is crucial in this context. Choice A, a temperature of 102�F and a productive cough, is common in pneumonia cases and not as concerning as a mediastinal shift. Choice B, ABGs with a PaO2 of 92 mmHg and PaCO2 of 40 mmHg, shows values within normal limits and does not suggest a tension pneumothorax. Choice D, a barrel-chested appearance, is typical of COPD and not directly related to the acute traumatic injury described. A tension pneumothorax is a medical emergency where air cannot escape the pleural cavity, leading to lung collapse and a mediastinal shift to the unaffected side with a downward displacement of the diaphragm.

4. A client is 36 hours post-op a TKR surgery. 270 cc of sero-sanguinous fluid accumulates in the surgical drains. What action should the nurse take?

• A. Notify the doctor
• B. Empty the drain
• C. Do nothing
• D. Remove the drain

Correct answer: A

Rationale: The correct action for the nurse to take in this situation is to notify the doctor. Significant sero-sanguinous drainage after TKR surgery could indicate a potential issue such as infection or bleeding. The physician needs to be informed promptly to assess the situation and determine the appropriate course of action. Emptying the drain, doing nothing, or removing the drain without consulting the physician could lead to complications going unnoticed or untreated. It is crucial to involve the physician in decision-making to ensure the best outcomes for the client.

5. A nurse is working in a pediatric clinic, and a 25-year-old mother comes in with a 4-week-old baby. The mother is stressed out about the loss of sleep, and the baby exhibits signs of colic. Which of the following techniques should the nurse teach the mother?

• A. Distraction of the infant with a red object
• B. Prone positioning techniques
• C. Tapping reflex techniques
• D. Neural warmth techniques

Correct answer: D

Rationale: Neural warmth techniques involve the caregiver providing a warm, soothing touch to the baby, which can help to lower the baby's agitation level and promote relaxation. This technique is beneficial for calming colicky babies. Choices A, B, and C are incorrect because distraction with a red object, prone positioning, and tapping reflex techniques are not effective methods for managing colic in infants. Red object distraction is not a proven technique for soothing colicky babies. Prone positioning is not recommended for infants due to the risk of sudden infant death syndrome (SIDS). Tapping reflex techniques are not recognized as effective interventions for colic.

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