Nursing Elites

1. A 1-month-old infant has a head measurement of 34 cm and a chest circumference of 32 cm. Based on the interpretation of these findings, what action would the nurse take?

• A. Refer the infant to a physician for further evaluation.
• B. Consider these findings normal for a 1-month-old infant.
• C. Expect the chest circumference to be greater than the head circumference.
• D. Ask the parent to return in 2 weeks to re-evaluate the head and chest circumferences.

Correct answer: B

Rationale: In infants, a normal head measurement is approximately 32 to 38 cm, and it is usually around 2 cm larger than the chest circumference. These measurements vary with age; between 6 months and 2 years, both measurements are approximately the same, and after age 2 years, the chest circumference becomes greater than the head circumference. Given that the 1-month-old infant's head measurement is within the typical range and slightly larger than the chest circumference, the nurse should consider these findings normal. There is no indication to refer the infant for further evaluation or to have the parent return for re-evaluation in 2 weeks, as these measurements fall within the expected parameters for a 1-month-old infant.

2. The supervising RN asks you to bring the unit's collected lab specimens to the lab 'stat'. You should ______________.

• A. not decline this task because nurses do not handle 'stats'.
• B. run this errand as promptly as possible
• C. run this errand immediately and without delay
• D. Complete this task before the end of your shift or after your lunch.

Correct answer: C

Rationale: In healthcare settings, 'stat' is commonly used to indicate that something should be done immediately and without any delay. It is a critical term used to prioritize urgent tasks. Nurses are responsible for various tasks, including handling urgent requests such as transporting lab specimens promptly. Option A is incorrect as nurses can handle urgent tasks like 'stats'. Option B is not as specific as option C, which clearly emphasizes the need for immediate action. Option D is incorrect as it suggests delaying the task until later, which goes against the urgency implied by the term 'stat'.

3. What type of blood pressure measurement error is most likely to occur if the nurse does not check for the presence of an auscultatory gap?

• A. Diastolic blood pressure may not be heard.
• B. Diastolic blood pressure may be falsely low.
• C. Systolic blood pressure may be falsely low.
• D. Systolic blood pressure may be falsely high.

Correct answer: C

Rationale: If an auscultatory gap is undetected, a falsely low systolic reading may occur. This gap can lead to an underestimation of the systolic blood pressure, causing potential misinterpretation of the patient's condition. The diastolic blood pressure may not be heard due to the gap, but the critical issue in this scenario is the risk of underestimating systolic blood pressure, which can impact clinical decision-making. Choices B, C, and D are incorrect because the key concern in this context is the potential for a falsely low systolic blood pressure reading when an auscultatory gap is not assessed.

4. During the evaluation of the quality of home care for a client with Alzheimer's disease, the priority for the nurse is to reinforce which statement by a family member?

• A. "At least two (2) full meals a day are eaten."?
• B. "We go to a group discussion every week at our community center."?
• C. "We have safety bars installed in the bathroom and have 24-hour alarms on the doors."?
• D. "The medication is not a problem to have taken three (3) times a day."?

Correct answer: C

Rationale: The correct answer is, '"We have safety bars installed in the bathroom and have 24-hour alarms on the doors."?' Ensuring the safety of a client with Alzheimer's disease is crucial in home care. Installing safety features like bars in the bathroom and alarms on doors help prevent accidents and injuries. This contributes to creating a safe environment that promotes independence and autonomy for the client. Choices A, B, and D are incorrect because while they are important aspects of care, ensuring safety in the home environment takes precedence in caring for a client with Alzheimer's disease.

5. The nurse is preparing to perform a physical assessment. The correct action by the nurse is reflected by which statement?

• A. Performs the examination from both sides of the bed.
• B. Examines tender or painful areas last to help relieve the patient's anxiety.
• C. Follows a flexible examination sequence, considering the patient's age and condition.
• D. Organizes the assessment to ensure that the patient does not change positions too often.

Correct answer: D

Rationale: The nurse should organize the assessment to minimize the patient's need to change positions frequently, ensuring efficiency and comfort. It is essential to perform the examination from both sides of the bed to facilitate a comprehensive assessment. Examining tender or painful areas last can help reduce patient discomfort and anxiety. The examination sequence should be flexible, taking into account the patient's age, condition, and specific needs. This approach allows for a tailored and patient-centered assessment, optimizing the quality of care provided.

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