Nursing Elites

1. A 4-month-old child is at the clinic for a well-baby checkup and immunizations. Which of these actions is most appropriate when the nurse is assessing an infant's vital signs?

• A. The infant's radial pulse should be palpated, and the nurse should notice any fluctuations resulting from activity or exercise.
• B. The nurse should auscultate an apical rate for 1 minute and then assess for any normal irregularities, such as sinus dysrhythmia.
• C. The infant's blood pressure should be assessed by using a stethoscope with a large diaphragm piece to hear the soft muffled Korotkoff sounds.
• D. The infant's chest should be observed and the respiratory rate counted for 1 minute; the respiratory pattern may vary significantly.

Correct answer: B

Rationale: The nurse auscultates an apical rate, not a radial pulse, with infants and toddlers. The pulse should be counted by listening to the heart for 1 full minute to account for normal irregularities, such as sinus dysrhythmia. Children younger than 3 years of age have such small arm vessels; consequently, hearing Korotkoff sounds with a stethoscope is difficult. The nurse should use either an electronic blood pressure device that uses oscillometry or a Doppler ultrasound device to amplify the sounds. An infant's respiratory rate should be assessed by observing the infant's abdomen, not chest, because an infant's respirations are normally more diaphragmatic than thoracic. The nurse should auscultate an apical heart rate, not palpate a radial pulse, with infants and toddlers.

2. A 75-year-old man with a history of hypertension was recently changed to a new antihypertensive drug. He reports feeling dizzy at times. How would the nurse evaluate his blood pressure?

• A. Blood pressure and pulse should be recorded in the supine, sitting, and standing positions.
• B. The patient should be directed to walk around the room and his blood pressure assessed after this activity.
• C. Blood pressure and pulse are assessed at the beginning and at the end of the examination.
• D. Blood pressure is taken on the right arm and then 5 minutes later on the left arm.

Correct answer: A

Rationale: Orthostatic vital signs should be taken when the person is hypertensive or is taking antihypertensive medications, when the person reports fainting or syncope, or when volume depletion is suspected. The blood pressure and pulse readings are recorded in the supine, sitting, and standing positions.

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

• A. Have the parent remove all clothing except the diaper.
• B. Instruct the parent not to feed the infant immediately before the examination.
• C. Allow the infant to suck on a pacifier during abdominal auscultation.
• D. Ensure the parent is present during the examination.

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.

4. When percussing over the abdomen of an obese patient, the nurse is unable to identify any changes in sound. What would the nurse do next?

• A. Ask the patient to take deep breaths to relax the abdominal musculature.
• B. Consider this finding as normal and proceed with the abdominal assessment.
• C. Increase the amount of strength used when attempting to percuss over the abdomen.
• D. Decrease the amount of strength used when attempting to percuss over the abdomen.

Correct answer: C

Rationale: When percussing an obese patient's abdomen, the thickness of their body wall can affect the sound produced. A stronger percussion stroke is needed for obese or very muscular patients. The force of the blow determines the loudness of the note. Asking the patient to take deep breaths, considering the finding as normal, or decreasing the strength used are not appropriate actions in this scenario.

5. The nurse is planning care for a patient with a wrist restraint. How often should a restraint be removed, the area massaged, and the joints moved through their full range?

• A. Once a shift
• B. Once an hour
• C. Every 2 hours
• D. Every 4 hours

Correct answer: C

Rationale: Restraints should be removed every 2 hours to prevent complications. Moving the joints through their full range of motion helps prevent muscle shortening and contractures. Massaging the area promotes circulation and reduces the risk of pressure injuries. Removing restraints less frequently could lead to complications like decreased circulation and skin breakdown. Options A, B, and D are incorrect because they do not align with the standard practice of removing restraints every 2 hours to ensure patient safety and well-being.

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