Nursing Elites

1. A nurse is teaching the mother of an 11-month-old infant how to clean the infant's teeth. The nurse tells the mother to take which action?

• A. Use a small amount of toothpaste and a soft-bristle toothbrush
• B. Use water and a cotton swab and rub the teeth
• C. Use diluted fluoride and rub the teeth with a soft washcloth
• D. Dip the infant's pacifier in maple syrup so that the infant will suck

Correct answer: C

Rationale: The correct action when cleaning an infant's teeth is to use water and a cotton swab to gently rub the teeth. This method helps in removing any food particles or plaque buildup without the risks associated with toothpaste ingestion. Using a small amount of toothpaste and a soft-bristle toothbrush is not recommended for infants as they may swallow the toothpaste, leading to potential fluoride ingestion issues. Using diluted fluoride and rubbing the teeth with a soft washcloth is unnecessary at this age since infants typically receive fluoride through other sources like formula. Dipping the infant's pacifier in maple syrup is highly inappropriate and poses a significant risk of tooth decay due to the high sugar content, which can harm the infant's teeth.

2. The nurse is assigning staff for the day. Which assignment should be given to the nursing assistant?

• A. Taking the vital signs of the 5-month-old with bronchiolitis
• B. Taking the vital signs of the 10-year-old with a 2-day postappendectomy
• C. Administering medication to the 2-year-old with periorbital cellulitis
• D. Adjusting the traction of the 1-year-old with a fractured tibia

Correct answer: B

Rationale: The most appropriate assignment for a nursing assistant is to take the vital signs of a stable patient. A 10-year-old with a 2-day postappendectomy is considered stable, and routine vital signs monitoring can be safely delegated to a nursing assistant. Clients with bronchiolitis, periorbital cellulitis, and a fractured tibia require more specialized care and assessment by a licensed nurse. Bronchiolitis involves an airway alteration, periorbital cellulitis indicates an infection, and a fractured tibia may raise concerns of abuse. Therefore, options A, C, and D are incorrect for delegation to a nursing assistant.

3. The difference between spirituality and religion is that spirituality is:

• A. a belief about a higher power.
• B. an individual's relationship with a higher power.
• C. organized worship.
• D. a belief in an invisible energy or ideal.

Correct answer: B

Rationale: The correct answer is 'an individual's relationship with a higher power.' Spirituality is more about personal connection, beliefs, and experiences related to a higher power or force, whereas religion is often associated with organized practices, rituals, and doctrines within a specific faith community. Choice A is incorrect as spirituality goes beyond just believing in a higher power; it encompasses a personal connection. Choice C, 'organized worship,' is incorrect because spirituality can exist outside formal religious settings. Choice D is incorrect as it oversimplifies spirituality as merely a belief in an invisible energy or ideal, missing the relational aspect with a higher power.

4. The nurse is caring for a client with epilepsy who is being treated with carbamazepine (Tegretol). Which laboratory value might indicate a serious side effect of this drug?

• A. Uric acid of 5 mg/dL
• B. Hematocrit of 33%
• C. WBC 2,000 per cubic millimeter
• D. Platelets 150,000 per cubic millimeter

Correct answer: C

Rationale: Carbamazepine (Tegretol) can suppress the bone marrow, leading to a decrease in the white blood cell count. A laboratory value of WBC 2,000 per cubic millimeter indicates a serious side effect of the drug. Choices A and D are within normal limits, while choice B is at the lower limit of normal. Therefore, choices A, B, and D are incorrect.

5. The client is receiving heparin for thrombophlebitis of the left lower extremity. Which of the following drugs reverses the effects of heparin?

• A. Cyanocobalamin
• B. Protamine sulfate
• C. Streptokinase
• D. Sodium warfarin

Correct answer: B

Rationale: The correct answer is Protamine sulfate. Protamine sulfate is the antidote for heparin, as it reverses its effects. Cyanocobalamin is a form of Vitamin B12 and is not used to reverse heparin effects. Streptokinase is a thrombolytic agent that is used to dissolve blood clots, not to reverse heparin effects. Sodium warfarin is an anticoagulant, but it is not the antidote for heparin. Therefore, answers A, C, and D are incorrect as they do not reverse the effects of heparin.

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