Nursing Elites

1. The mother of a 5-month-old is being educated about her baby's nutrition by the nurse. Which statement by the mother indicates the need for further teaching?

• A. ''I'm going to try feeding my baby some rice cereal.''
• B. ''When he wakes at night for a bottle, I feed him.''
• C. ''I dip his pacifier in honey so he'll take it.''
• D. ''I keep formula in the refrigerator for 24 hours.''

Correct answer: C

Rationale: The correct answer is ''I dip his pacifier in honey so he'll take it.'' This statement indicates a need for further teaching because honey should be avoided in infants due to the risk of infant botulism. Honey may contain spores of Clostridium botulinum, which can lead to serious illness in infants as they lack the necessary digestive enzymes to eliminate the spores. Feeding rice cereal, responding to night-time feedings, and storing formula in the refrigerator are appropriate practices for infant care, indicating understanding of the instructions.

2. The nurse assesses a 2-year-old who is admitted for dehydration and finds that the peripheral IV rate by gravity has slowed, even though the venous access site is healthy. What should the nurse do next?

• A. Apply a warm compress proximal to the site.
• B. Check for kinks in the tubing and raise the IV pole.
• C. Adjust the tape that stabilizes the needle.
• D. Change the IV solution bag.

Correct answer: B

Rationale: When a nurse assesses a slowed IV rate by gravity with a healthy venous access site in a 2-year-old admitted for dehydration, the next step would be to check for kinks in the tubing and raise the IV pole. This action ensures that the IV fluid can flow freely and reach the patient at the correct rate. Applying a warm compress proximal to the site (Choice A) is not indicated in this situation as it does not address the underlying issue of a slowed IV rate due to mechanical factors. Adjusting the tape that stabilizes the needle (Choice C) or changing the IV solution bag (Choice D) are not the priority actions in this case. These choices do not address the issue of a slowed IV rate caused by kinks in the tubing or the height of the IV pole, which are more likely reasons for the problem observed.

3. A patient with major depression who has lost 20 pounds in one month, has chronic low self-esteem, and a plan for suicide. The patient has taken an antidepressant medication for 1 week. Which nursing intervention is most directly related to this outcome: 'Patient will refrain from gestures and attempts to harm self'?

• A. Implement suicide precautions.
• B. Frequently offer high-calorie snacks and fluids.
• C. Assist the patient to identify three personal strengths.
• D. Observe patient for therapeutic effects of antidepressant medication.

Correct answer: A

Rationale: Implementing suicide precautions is the most critical intervention in this scenario as it directly addresses the patient's safety and the prevention of self-harm. The patient's significant weight loss, chronic low self-esteem, suicide plan, and recent initiation of an antidepressant medication indicate a high risk of self-harm. Suicide precautions involve close monitoring, removing harmful objects, and ensuring a safe environment to prevent the patient from acting on suicidal thoughts. While offering high-calorie snacks and fluids, assisting the patient in identifying personal strengths, and observing for therapeutic effects of the antidepressant are important aspects of care, they do not directly address the immediate risk of self-harm that implementing suicide precautions does.

4. During a routine assessment, an obese 50-year-old female client expresses concern about her sexual relationship with her husband. Which is the best response by the nurse?

• A. Reassure the client that many obese individuals have concerns about sex.
• B. Remind the client that sexual relationships can remain unaffected by obesity.
• C. Determine the frequency of sexual intercourse.
• D. Ask the client to talk about specific concerns.

Correct answer: D

Rationale: Option D is the best response as it allows the client to express her specific concerns, providing the nurse with valuable assessment data. This open-ended question encourages the client to share her worries and feelings, which can guide the nurse in addressing her unique needs. Options A and B make assumptions about the client's concerns based on her weight, potentially invalidating her feelings and inhibiting effective communication. Option C is premature as understanding the client's concerns should precede discussions about the frequency of sexual intercourse, which may not address the core issues the client is facing.

5. Which action should the nurse implement when providing wound care instructions to a client who does not speak English?

• A. Ask an interpreter to provide wound care instructions.
• B. Speak directly to the client, with an interpreter translating.
• C. Request the accompanying family member to translate.
• D. Instruct a bilingual employee to read the instructions.

Correct answer: B

Rationale: When providing wound care instructions to a client who does not speak English, the nurse should speak directly to the client with the assistance of an interpreter for accurate translation. The interpreter is trained to provide objective translations in the client's primary language, ensuring the client understands the instructions and can ask questions. Using family members for translation is discouraged as they may alter instructions or feel uncomfortable discussing certain topics. Instructing a bilingual employee to read the instructions is not ideal as they may lack the necessary training in accurate interpretation, which could lead to misunderstandings in crucial wound care instructions.

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