the nurse is counting an infants respirations which technique is correct
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Nursing Elites

NCLEX-RN

Exam Cram NCLEX RN Practice Questions

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

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. When is the best time for the nurse to attempt to elicit the Moro reflex during an infant examination?

Correct answer: B

Rationale: The Moro reflex, also known as the startle reflex, is best elicited at the end of the examination because it can cause the infant to cry. This reflex is triggered by a sudden change in position or loud noise, and it involves the infant's arms extending and then coming back together as if embracing. By eliciting this reflex at the end of the examination, the nurse can observe the infant's response and ensure that the examination is completed without unnecessary distress. Choices A, C, and D are incorrect because the Moro reflex is typically elicited at the end of the examination to avoid disrupting the assessment process and causing unnecessary discomfort to the infant.

3. What is the primary route of transmission of MRSA?

Correct answer: B

Rationale: The correct answer is 'Hands of healthcare workers.' MRSA is primarily transmitted via the unwashed hands of healthcare workers who can carry the Staphylococcus aureus bacterium from one patient to another. Shared needles, items in the healthcare environment, and blood transfusions are not the main routes of transmission for MRSA. Shared needles can transmit bloodborne pathogens, items in the healthcare environment can harbor bacteria but are not the primary mode for MRSA, and blood transfusions are not a common route for MRSA transmission.

4. Who should be members of a patient care conference?

Correct answer: D

Rationale: In a patient care conference, it is essential to have all members of the healthcare team present to ensure comprehensive and coordinated care. Including the patient or resident, along with their family members if desired, is crucial as they are the focus of care. Choice A is incorrect because it excludes other important members of the healthcare team. Choice B is partially correct as it includes the patient and/or family members but does not encompass the entire healthcare team. Choice C is too broad and does not specifically address the inclusion of the patient or resident. The correct answer, Choice D, includes all healthcare team members and the patient/resident, ensuring a holistic approach to patient-centered care.

5. A patient's urine specimen tested positive for bilirubin. Which of the following is most true?

Correct answer: D

Rationale: Bilirubin is easily broken down by light, so all samples testing positive for bilirubin should be protected from light exposure. Storing the specimen in an area protected from light helps maintain the integrity of the bilirubin levels for accurate testing. Choice A is incorrect because the presence of bilirubin in urine does not necessarily indicate kidney disease. Choice B is incorrect as the exposure to light, not room temperature, affects bilirubin levels. Choice C is incorrect as the presence of bilirubin does not indicate the presence of bacteria in the specimen.

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