Nursing Elites

1. A new mother asks the nurse if the newborn infant has an infection because the healthcare provider prescribed a blood test called the TORCH screen test. Which response should the nurse offer to the mother's inquiry?

• A. Rising titers identify the etiology of certain neuro-sensory birth defects
• B. The screen determines the risk for inherited anomalies in the newborn
• C. The test identifies the correct antibiotic to give the newborn for an infection
• D. Exposure to infections that can cross the placenta cause a positive antibody titer

Correct answer: D

Rationale: The TORCH screen test is used to detect infections that can affect the newborn by showing if there was exposure to these infections. Choice A is incorrect because the TORCH screen test is not specifically for identifying the etiology of neuro-sensory birth defects. Choice B is incorrect because the test does not determine the risk for inherited anomalies. Choice C is incorrect because the test is not used to identify the correct antibiotic for an infection, but rather to detect infections that may have affected the newborn.

2. The nurse is preparing to send a client to the cardiac catheterization lab for an angioplasty. Which client report is most important for the nurse to explore further prior to the start of the procedure?

• A. Verbalizes a fear of being in a confined space.
• B. Drank a glass of water in the past 2 hours.
• C. Reports left chest wall pain prior to admission.
• D. Experiences facial swelling after eating crab

Correct answer: C

Rationale: The correct answer is C. Left chest wall pain could indicate ongoing cardiac issues or instability, which needs to be assessed before proceeding with the procedure. This pain could be related to the heart and may suggest a potential risk during the angioplasty. Options A, B, and D do not directly relate to cardiac complications during the procedure, making them less urgent for immediate assessment. Fear of confined spaces, drinking water, and facial swelling after eating crab are not immediate risks to the client's safety in the context of a cardiac catheterization procedure.

3. The nurse is assessing a 3-month-old infant who had a pylorotomy yesterday. This child should be medicated for pain based on which finding?

• A. Restlessness
• B. Clenched Fist
• C. Increased pulse rate
• D. Increased respiratory rate

Correct answer: A

Rationale: In infants, restlessness can be a significant indicator of discomfort or pain, necessitating appropriate pain management. While choices B, C, and D can also be associated with pain, restlessness is a more general and reliable indicator in this scenario. A clenched fist might indicate pain or distress, but it is not as specific as restlessness in assessing pain in infants. Increased pulse rate and respiratory rate can be influenced by various factors other than pain, making them less reliable indicators of pain in this context.

4. The nurse administers an oral antiviral to a client with shingles. Which finding is most important for the nurse to report to the healthcare provider?

• A. Decreased white blood cell count
• B. Pruritus and muscle aches
• C. Elevated liver function tests
• D. Vomiting and diarrhea

Correct answer: C

Rationale: The correct answer is C: Elevated liver function tests. When administering antivirals, especially orally, monitoring liver function tests is crucial as it may indicate liver toxicity. This finding should be reported promptly to the healthcare provider to prevent further complications. Choice A, decreased white blood cell count, may be expected with certain antivirals but is not the most critical finding in this scenario. Pruritus and muscle aches (choice B) are common side effects of antivirals and do not require immediate reporting. Vomiting and diarrhea (choice D) are also common side effects that may not be as concerning as elevated liver function tests.

5. A postpartum client who is bottle feeding develops breast engorgement. What is the best recommendation for the nurse to provide this client?

• A. Take a prescribed analgesic and expose breasts to air
• B. Place warm packs on both breasts
• C. Avoid stimulation of the breasts and wear a tight bra
• D. Express a small amount of breast milk by hand

Correct answer: C

Rationale: For a postpartum client who is bottle feeding and develops breast engorgement, the best recommendation is to avoid stimulation of the breasts and wear a tight bra. This helps reduce engorgement by decreasing blood flow to the breasts. Option A is incorrect because exposing the breasts to air can further stimulate them, worsening engorgement. Option B is incorrect as warm packs can increase blood flow and exacerbate engorgement. Option D is incorrect as expressing breast milk can lead to further stimulation and increased engorgement.

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