Nursing Elites

1. A 2-year-old child has been brought to the clinic for a well-child checkup. What is the best way for the nurse to begin the assessment?

• A. Ask the parent to place the child on the examining table.
• B. Have the parent remove all of the child's clothing before the examination.
• C. Allow the child to keep a security object such as a toy or blanket during the examination.
• D. Initially focus the interactions on the child, essentially ignoring the parent until the child's trust has been obtained.

Correct answer: C

Rationale: The best place to examine the toddler is on the parent's lap. Toddlers understand symbols; therefore, a security object is helpful. Initially, the focus is more on the parent, which allows the child to adjust gradually and to become familiar with you. A 2-year-old child does not like to take off his or her clothes. Therefore, ask the parent to undress one body part at a time.

2. You have measured the urinary output of your resident at the end of your 8-hour shift. The output is 25 ounces. What should you do next?

• A. Convert the number of ounces into cc.
• B. Convert the number of ounces into cm.
• C. Immediately report this poor output to the nurse.
• D. Know that 25 ounces of urine is too much in 8 hours.

Correct answer: A

Rationale: You should convert the number of ounces into cc because cc is the unit of measurement used to record intake and output accurately. This urinary output falls within normal limits, so there is no need to report it immediately to the nurse. It is essential to report urinary outputs of less than 30 cc per hour to detect potential issues early. Converting ounces into centimeters (cm) is not appropriate in this context as cm is a unit of length, not volume. Knowing that 25 ounces of urine is too much in 8 hours is inaccurate as it depends on various factors like fluid intake and individual differences.

3. A healthcare professional is considering which patient to admit to the same room as a patient who had a liver transplant 3 weeks ago and is now hospitalized with acute rejection. Which patient would be the best choice?

• A. Patient who is receiving chemotherapy for liver cancer
• B. Patient who is receiving chemotherapy for lung cancer
• C. Patient who has a wound infection after cholecystectomy
• D. Patient who requires pain management for chronic pancreatitis

Correct answer: D

Rationale: The patient with chronic pancreatitis is the best choice to admit to the same room as a patient who had a liver transplant and is experiencing acute rejection. This is because the patient with chronic pancreatitis does not pose an infection risk to the immunosuppressed patient who had a liver transplant. On the other hand, patients receiving chemotherapy for cancer or those with wound infections are at risk for infections, which could endanger the immunosuppressed patient with acute rejection.

4. A client with expressive aphasia is pointing wildly at the bath water but unable to speak. Which response from the nurse is most appropriate?

• A. Is something wrong with the bath water?
• B. Just calm down, we'll finish your bath soon.
• C. Are you trying to tell me something?
• D. Shall I turn on the television?

Correct answer: A

Rationale: A client with expressive aphasia faces difficulty expressing themselves verbally but can understand others. In this scenario, the client's gestures indicate a communication attempt. The nurse's best response is to directly address the potential issue the client is indicating, which is the bath water. Option A acknowledges the client's non-verbal communication and seeks to address their concern. Choices B, C, and D do not directly address the client's attempt to communicate about the bath water, which is the focal point of the interaction.

5. After taking the vital signs for your patient and finding them to be normal, what should you do next?

• A. Report the vital signs to the doctor
• B. Write the vital signs on a scrap paper
• C. Call the family members
• D. Document them on the graphic VS form

Correct answer: D

Rationale: After assessing and finding that the vital signs are normal for the patient, the appropriate action would be to document them on the graphic VS form. This form is used to track and record vital sign measurements accurately and consistently. Reporting the normal vital signs to the doctor is not necessary unless there are concerning trends or deviations. Writing the vital signs on a scrap piece of paper is not recommended as it may not be an official or reliable record. Calling the family members is unrelated to the process of documenting and tracking vital signs for the patient.

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