which would the nurse do when preparing to perform a physical examination on an infant
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NCLEX-RN

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1. When preparing to perform a physical examination on an infant, what should the nurse do?

Correct answer: A

Rationale: For performing a physical examination on an infant, it is important to have the parent remove all clothing except the diaper to allow for a thorough examination while ensuring the infant remains comfortable. It is recommended not to feed the infant immediately before the examination but rather 1 to 2 hours after feeding when the baby is neither too drowsy nor too hungry. While a pacifier may be used during invasive assessments or if the infant is crying, it is not typically necessary during abdominal auscultation. Having the parent present during the examination is important for the infant's security and for the parent to understand the process; however, the clothing should still be removed except for the diaper to facilitate a comprehensive assessment.

2. A patient states, "I'm not worth anything. I have negative thoughts about myself. I feel anxious and shaky all the time. Sometimes I feel so sad that I want to go to sleep and never wake up."? Which nursing intervention should have the highest priority?

Correct answer: D

Rationale: The highest priority nursing intervention in this scenario should be suicide precautions. The patient's statement indicates suicidal ideation, which poses an immediate risk to their safety. By implementing suicide precautions, the nurse can ensure constant monitoring and intervention to prevent any self-harm. While addressing self-esteem, anxiety, and sleep issues are essential, ensuring the patient's safety by prioritizing suicide precautions is crucial. Self-esteem-building activities, anxiety self-control measures, and sleep enhancement activities are important interventions but should follow the immediate concern of preventing harm from suicidal thoughts.

3. The nurse is teaching a student nurse about the different types of thermometers. When teaching the student about the advantages of the tympanic membrane thermometer (TMT), which statement would the nurse include?

Correct answer: B

Rationale: The correct answer is "The rapid measurement of the TMT is beneficial for uncooperative younger children." TMT is ideal for young children who may not cooperate for oral temperatures or fear rectal temperatures. However, using TMT for newborn infants is not recommended due to inconsistencies in results. Measuring temperature with TMT is not necessarily cost-effective. The most accurate method for measuring core temperature is through rectal temperatures. TMT may not be the preferred method for patients with otitis media due to potential inaccuracies caused by fluid behind the tympanic membrane.

4. Which of the following is an example of an environmental hazard that may put the healthcare professional at risk of injury?

Correct answer: D

Rationale: Healthcare professionals, including nurses, are exposed to various environmental hazards that may negatively impact their physical or mental health. Hazards come in several forms, such as loud noise from hospital systems, which can damage hearing; airborne latex powder, leading to allergic reactions; and chemicals like ethylene oxide, a sterilizing agent that can cause cancer. Therefore, all the options listed pose risks to healthcare professionals, making 'All of the above' the correct answer. Choice A, loud noise, is a hazard that can affect hearing health. Choice B, airborne latex powder, can trigger allergic responses. Choice C, chemicals containing ethylene oxide, are hazardous and can lead to serious health issues. Each option represents a distinct environmental risk that healthcare professionals should be aware of and take precautions against.

5. You are working the 8 am to 4 pm shift. You begin to vomit at 3 pm and you do not think that you are able to continue working. You decide to immediately go home without notifying your RN supervisor. You have ________________.

Correct answer: D

Rationale: Patient abandonment is a serious violation that can lead to disciplinary action and immediate termination of employment. It is defined as leaving patients without proper consent from the supervisor. In this scenario, leaving work without notifying the RN supervisor and potentially leaving patients unattended is considered patient abandonment, as it compromises patient safety and care. Choices A and B are incorrect because having sick time or finishing work does not justify leaving without proper protocol. Choice D is incorrect as the scenario does not indicate abuse or neglect towards the patients.

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