Nursing Elites

1. When counting an infant's respirations, which technique is correct?

• A. Watching the chest rise and fall
• B. Observing the movement of the abdomen
• C. Placing a hand across the infant's chest
• D. Using a stethoscope to listen to the breath sounds

Correct answer: B

Rationale: The correct technique for counting an infant's respirations is to observe the movement of the abdomen. Infants typically have more diaphragmatic breathing than thoracic, so watching the abdomen provides a more accurate count. Placing a hand on the chest or listening with a stethoscope can alter the infant's breathing pattern and provide inaccurate results. Therefore, options A, C, and D are incorrect methods for counting an infant's respirations. By observing the movement of the abdomen, healthcare providers can accurately assess an infant's respiratory rate without influencing their breathing pattern.

2. What does the medical term 'diaphoresis' mean?

• A. Profuse vomiting
• B. Profuse sweating
• C. Gasping for air
• D. None of the above

Correct answer: B

Rationale: The correct answer is B: Profuse sweating. Diaphoresis is a medical term that refers to excessive sweating. It is commonly seen in emergency situations such as heart attacks or diabetic episodes. Choice A, 'Profuse vomiting,' is incorrect as diaphoresis is not related to vomiting. Choice C, 'Gasping for air,' is also incorrect as it refers to difficulty breathing, not sweating. Choice D, 'None of the above,' is incorrect as diaphoresis specifically relates to sweating.

3. On admission to the psychiatric unit, the client is trembling and appears fearful. The nurse's initial response should be to:

• A. Give the client orientation materials and review the unit rules and regulations.
• B. Introduce him/her and accompany the client to the client's room.
• C. Take the client to the day room and introduce him/her to the other clients.
• D. Ask the nursing assistant to get the client's vital signs and complete the admission search.

Correct answer: B

Rationale: Anxiety is triggered by change that threatens the individual's sense of security. In response to anxiety in clients, the nurse should remain calm, minimize stimuli, and move the client to a calmer, more secure/safe setting. The correct initial response is to introduce the client and accompany them to their room. This approach helps the client feel oriented, safe, and supported. Giving orientation materials or reviewing rules and regulations may overwhelm the client further. Taking the client to the day room and introducing them to other clients could increase anxiety by exposing them to unfamiliar faces. Asking the nursing assistant to get vital signs and complete admission tasks can wait until the client feels more settled and secure in their environment.

4. Which contraindication should be assessed for prior to administering an immunization to a child?

• A. Mild cold symptoms
• B. Chronic asthma
• C. Depressed immune system
• D. Allergy to eggs

Correct answer: C

Rationale: Before administering immunizations to children, it is crucial to assess for contraindications. A depressed immune system, such as that seen in conditions like HIV or due to chemotherapy, is a significant contraindication. Immunizations may not be safe or effective in children with compromised immune systems. Mild cold symptoms, although not ideal, are not a contraindication for routine immunizations. Chronic asthma, while a consideration, is not a direct contraindication for routine immunizations. Allergy to eggs is a contraindication for specific vaccines, such as influenza vaccine that is grown in eggs, but it is not a contraindication for all immunizations.

5. The nursing diagnosis is Risk for impaired skin integrity related to immobility and pressure secondary to pain and presence of a cast. Which of the following desired outcomes should the nurse include in the care plan?

• A. Client will be able to turn self by day 3
• B. Skin will remain intact and without redness during hospital stay
• C. Client will state pain relieved within 30 minutes after medication
• D. Pressure will be prevented by repositioning client every 2 hours

Correct answer: B

Rationale: The correct desired outcome for a nursing diagnosis of 'Risk for impaired skin integrity' is to ensure that the skin remains intact and without redness during the hospital stay. This outcome directly addresses the risk identified in the diagnosis. Option A focuses on addressing immobility, which is not the priority for this diagnosis. Option C deals with pain relief, which is a separate concern. Option D is an intervention involving pressure prevention through repositioning, rather than an outcome related to skin integrity.

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