Nursing Elites

1. A parent asks a nurse about his infant's expected physical development during the first year of life. Which of the following information should the nurse include?

• A. A 10-month-old infant can pull up to a standing position.
• B. A 6-month-old infant can walk with assistance.
• C. A 12-month-old infant can jump with both feet.
• D. An 8-month-old infant can crawl on hands and knees.

Correct answer: A

Rationale: The correct answer is A. By 10 months, infants can typically pull up to a standing position as part of their physical development. Walking with assistance usually begins around 9-12 months, not at 6 months (choice B). Jumping with both feet is a skill that usually develops around 24 months, not at 12 months (choice C). Crawling on hands and knees typically starts around 6-9 months, not at 8 months (choice D). Therefore, the most accurate information to include for an infant's expected physical development at 10 months is the ability to pull up to a standing position.

2. When should the nurse plan to collect a sputum specimen for culture and sensitivity as ordered by a client's provider?

• A. In the morning upon rising.
• B. Immediately after the client eats breakfast.
• C. Before the client goes to bed.
• D. After the client has had a drink of water.

Correct answer: A

Rationale: The correct time to collect a sputum specimen for culture and sensitivity is in the morning upon rising. This timing ensures the most concentrated sample as sputum produced overnight tends to accumulate and sit in the airways, providing a quality sample for testing. Collecting the specimen immediately after eating breakfast (choice B) may introduce food particles that could contaminate the sample. Collecting it before bed (choice C) may lead to a diluted sample due to daily activities. Collecting the specimen after having a drink of water (choice D) can also result in a diluted sample, impacting the accuracy of the test results.

3. At 0100 on a male client's second postoperative night, the client states he is unable to sleep and plans to read until feeling sleepy. What action should the nurse implement?

• A. Stay with the client and offer assistance with relaxation techniques
• B. Assess the client's pain level and administer pain medication if needed
• C. Bring the client a prescribed PRN sedative-hypnotic
• D. Encourage the client to engage in a quiet, non-stimulating activity until feeling sleepy

Correct answer: C

Rationale: At 0100 on the client's second postoperative night, the nurse should address the client's inability to sleep. Providing a prescribed PRN sedative-hypnotic is appropriate in this situation to help the client rest. Choice A is incorrect because leaving the room and closing the door does not directly address the client's sleep concern. Choice B is not the priority at this moment since the client's main issue is insomnia, not pain. Choice D, while encouraging a non-stimulating activity, does not provide immediate relief for the client's sleeplessness as a sedative-hypnotic would.

4. A nurse is caring for a client who has a new prescription for tube feeding. The nurse understands that the provider prescribed tube feeding because the client:

• A. Is unable to swallow foods by mouth
• B. Has a gastrointestinal obstruction
• C. Requires additional caloric intake to support healing
• D. Is at risk for aspiration

Correct answer: A

Rationale: The correct answer is A: 'Is unable to swallow foods by mouth.' Tube feeding is prescribed when a client is unable to safely swallow food by mouth but has a functional gastrointestinal tract. Option B, 'Has a gastrointestinal obstruction,' is incorrect as tube feeding is not typically prescribed for this reason. Option C, 'Requires additional caloric intake to support healing,' is incorrect because tube feeding is specifically for clients who are unable to swallow. Option D, 'Is at risk for aspiration,' is also incorrect as tube feeding would not be the primary intervention for aspiration risk; other strategies to reduce aspiration risk would be implemented instead.

5. Upon admission to the hospital, a client presents with decreased circulation in the left leg. What is the most important initial nursing action during the assessment?

• A. Assess the client's mobility
• B. Evaluate the pedal pulses
• C. Monitor skin temperature
• D. Check for swelling

Correct answer: B

Rationale: When a client is admitted with decreased circulation in the left leg, the most critical initial nursing action is to evaluate the pedal pulses. Pedal pulses provide essential information about the circulation status in the affected leg. Assessing the client's mobility (Choice A) is important but not as crucial as evaluating pedal pulses in this scenario. Monitoring skin temperature (Choice C) and checking for swelling (Choice D) are also relevant, but they are secondary to evaluating pedal pulses since the latter directly assesses the circulation in the affected limb.

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