Nursing Elites

1. A nurse in a day-care setting is planning play activities for 2- and 3-year-old children. Which toys are most appropriate for these activities?

• A. Finger paints and card games
• B. Blocks and push-pull toys
• C. Videos and cutting-and-pasting toys
• D. Simple board games and puzzles

Correct answer: B

Rationale: The most appropriate toys for 2- and 3-year-old children in a day-care setting are blocks and push-pull toys. Toddlers enjoy objects of different textures like clay, sand, finger paints, and bubbles, as well as push-pull toys, large balls, and sand and water play. They also like activities such as blocks, painting, coloring with large crayons, large puzzles, and playing with trucks or dolls. Finger paints and card games may be more suitable for older children. Videos and cutting-and-pasting toys are generally more appropriate for preschoolers. Blocks and push-pull toys are beneficial for young children as they help in developing fine motor skills, hand-eye coordination, spatial awareness, and creativity. These toys also encourage imaginative play and problem-solving, making them ideal choices for toddlers.

2. While assisting with data collection of an adult client, a nurse asks the client to identify various odors. In this technique, which cranial nerve is the nurse assessing?

• A. Optic
• B. Abducens
• C. Olfactory
• D. Hypoglossal

Correct answer: C

Rationale: The correct answer is 'Olfactory.' The olfactory nerve is responsible for the sense of smell. Assessing this nerve involves testing the client's ability to identify various odors. Loss of smell, head trauma, abnormal mental status, and suspected intracranial lesions are conditions where testing the olfactory nerve is essential. The optic nerve is evaluated for visual acuity and visual fields. The abducens nerve is usually assessed alongside the oculomotor and trochlear nerves, focusing on pupil size, regularity, light reactions, accommodation, and extraocular movements. The hypoglossal nerve is examined by inspecting the tongue, not by assessing the sense of smell.

3. A nurse is preparing to measure a client's calf circumference. The nurse performs this procedure by performing which action?

• A. Placing a tape measure around the widest point of the lower leg
• B. Measuring 2 inches above the knee and placing the tape measure around the client's leg at this point
• C. Measuring 2 inches above the ankle and placing the tape measure around the client's leg at this point
• D. Measuring 2 inches below the patella and placing the tape measure around the client's leg at this point

Correct answer: A

Rationale: To measure a client's calf circumference accurately, a nurse should place a non-stretchable tape measure around the widest point of the lower leg. It is crucial to ensure that the tape measure is positioned at the same number of centimeters down from a specific landmark, such as the patella, on both legs for consistency. Placing the tape measure 2 inches above the knee (Option B), 2 inches above the ankle (Option C), or 2 inches below the patella (Option D) would not provide an accurate measurement of the calf circumference. Therefore, these options are incorrect choices.

4. A nurse monitoring a newborn infant notes that the infant's respirations are 40 breaths/min. On the basis of this finding, what is the most appropriate action for the nurse to take?

• A. Contacting the registered nurse
• B. Documenting the findings
• C. Wrapping an extra blanket around the infant
• D. Placing the infant in an oxygen tent

Correct answer: B

Rationale: The normal respiratory rate of a newborn infant is 30 to 60 breaths/min, with an average of 40. Since the infant's respiratory rate falls within the normal range, the most appropriate action for the nurse is to document the findings. Contacting the registered nurse, placing the infant in an oxygen tent, or wrapping an extra blanket around the infant are unnecessary actions as the respiratory rate is normal. Documenting the findings is important to provide a record of the assessment and serve as a baseline for future comparisons if needed.

5. Which of the following is not a nursing responsibility when preparing the client for central line insertion?

• A. advancing the guidewire
• B. explaining the procedure to the client
• C. maintaining sterile technique
• D. ensuring necessary consents are signed

Correct answer: A

Rationale: When preparing a client for central line insertion, nursing responsibilities include explaining the procedure to the client, ensuring necessary consents are signed according to the facility policy, and maintaining sterile technique when preparing the equipment and supplies. Advancing the guidewire is typically performed by the practitioner inserting the central line, not the nurse. It requires specialized training and expertise beyond the scope of nursing practice. Therefore, the correct answer is advancing the guidewire. Option A is the correct answer because it delineates an activity that is not within the usual scope of nursing practice during central line insertion preparation. Options B, C, and D are incorrect as they reflect essential nursing responsibilities in this context.

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