Nursing Elites

1. A healthcare professional is preparing to measure an infant's temperature. Which of the following actions should the healthcare professional take?

• A. Place the tip of the thermometer under the center of the infant's axilla
• B. Pull the pinna of the infant's ear forward before inserting the probe
• C. Insert the probe 3.8 cm (1.5in) into the infant's rectum
• D. Insert the thermometer in front of the infant's tongue

Correct answer: A

Rationale: When measuring an infant's temperature, the most appropriate and non-invasive method is to place the tip of the thermometer under the center of the infant's axilla (armpit). This method is safe, quick, and comfortable for the infant. Inserting the probe into the rectum is invasive and not recommended for routine temperature measurement in infants. Inserting the thermometer in front of the infant's tongue is not a reliable method for measuring temperature. Pulling the pinna of the ear forward is a technique used for adults, not infants.

2. Which of the following signs and symptoms would the nurse expect to find when assessing an Asian patient for postoperative pain following abdominal surgery?

• A. Decreased blood pressure and heart rate and shallow respirations
• B. Quiet crying
• C. Immobility, diaphoresis, and avoidance of deep breathing or coughing
• D. Changing position every 2 hours

Correct answer: C

Rationale: Immobility, diaphoresis, and avoidance of deep breathing or coughing are common signs of pain.

3. What is a nurse's role in health promotion?

• A. Conducting health risk appraisals
• B. Educating clients to be effective health consumers
• C. Implementing worksite wellness programs
• D. None of the above

Correct answer: B

Rationale: A nurse plays a crucial role in health promotion by educating clients to be effective health consumers. This involves empowering individuals to make informed decisions about their health, access appropriate healthcare services, and engage in healthy behaviors to prevent illness and promote well-being. The other choices are not entirely accurate in describing the primary role of a nurse in health promotion. While nurses may conduct health risk appraisals and implement worksite wellness programs as part of their responsibilities, their central focus is on educating and empowering individuals to take control of their health.

4. A healthcare provider is reviewing the laboratory report of a client who has been taking lithium carbonate for the past 12 months. The provider notes a lithium level of 0.8 mEq/L. Which of the following orders from the provider should the healthcare provider expect?

• A. Withhold the next dose
• B. Increase the dosage
• C. Discontinue the medication
• D. Administer the medication

Correct answer: D

Rationale: A lithium level of 0.8 mEq/L falls within the therapeutic range for maintaining the drug's effectiveness while minimizing toxicity. Therefore, the appropriate action would be to continue administering the medication as prescribed by the healthcare provider to maintain the therapeutic effect for the client.

5. A nurse is orienting a newly licensed nurse on performing a routine assessment of a client who is receiving mechanical ventilation via an endotracheal tube. Which of the following information should the nurse include in the teaching?

• A. Apply a vest restraint if self-extubation is attempted.
• B. Monitor ventilator settings every 8 hours.
• C. Document tube placement in centimeters at the angle of the jaw.
• D. Assess breath sounds every 1 to 2 hours.

Correct answer: D

Rationale: Assessing breath sounds every 1 to 2 hours is crucial in monitoring the client's respiratory status and identifying any potential complications promptly. Monitoring ventilator settings every 8 hours is important for overall ventilation management. Documenting the endotracheal tube placement accurately is essential to ensure proper positioning. Using a vest restraint if self-extubation is attempted is not a recommended intervention as it can lead to complications and should be avoided.

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