Nursing Elites

1. A healthcare professional is preparing information for a change-of-shift report. Which of the following information should the healthcare professional include in the report?

• A. Input and output measurements for the shift
• B. Blood pressure readings from the previous day
• C. Bone scan scheduled for today
• D. Medication regimen from the medication administration record

Correct answer: D

Rationale: During a change-of-shift report, healthcare professionals should include the medication regimen from the medication administration record. This information ensures continuity of care and helps incoming staff understand the patient's medication needs and schedule. While input and output measurements, blood pressure readings, and scheduled procedures like a bone scan are important aspects of patient care, they may not be immediately relevant for the incoming shift. Focusing on medication details helps prevent errors and ensures the patient receives the correct medications at the right times.

2. A healthcare provider is assessing a client's ability to balance. Which of the following actions is appropriate when the healthcare provider conducts a Romberg test?

• A. Ask the client to extend their arms in front of their body.
• B. Ask the client to walk in a straight line heel to toe.
• C. Have the client stand with their feet together.
• D. Have the client place their hands on their hips.

Correct answer: C

Rationale: The Romberg test is a neurological test that assesses proprioception and balance. To perform this test, the client is asked to stand with their feet together and arms at their sides while closing their eyes. By removing visual input, the test challenges the vestibular and proprioceptive systems. Choices A, B, and D are incorrect because they do not align with the proper procedure for conducting the Romberg test. Extending arms in front, walking heel to toe, or placing hands on hips are not part of the Romberg test protocol and may introduce variables that could affect the assessment of balance.

3. A nurse is evaluating teaching about nutrition with the guardians of an 11-year-old child. Which of the following statements should indicate to the nurse an understanding of the teaching?

• A. “Our child wants to eat as much as we do, but we’re afraid it will lead to becoming overweight.”
• B. “Our child skips lunch sometimes, but we figure it’s okay as long as we eat a healthy breakfast and dinner.”
• C. “We limit fast-food restaurant meals to three times a week now.”
• D. “We reward school achievements with a point system instead of pizza or ice cream.”

Correct answer: D

Rationale: The correct answer is D. Rewarding school achievements with a point system rather than food items like pizza or ice cream is a healthier approach. This choice indicates an understanding of the teaching about nutrition and the importance of not using food as a reward. Choices A, B, and C do not demonstrate a clear understanding of the teaching as they focus on concerns about overeating, skipping meals, and limiting fast-food consumption but do not address the concept of avoiding food rewards for achievements.

4. When taking a history of a 3-year-old with neuroblastoma, what comment by the parents requires follow-up and is consistent with the diagnosis?

• A. The child has been listless and has lost weight.
• B. The urine is dark yellow and in small amounts.
• C. Clothes are becoming tighter across her abdomen.
• D. We notice muscle weakness and some unsteadiness.

Correct answer: C

Rationale: The correct answer is C. Clothes becoming tighter across the abdomen is indicative of an abdominal mass, a common presentation in neuroblastoma. This symptom should be followed up on further as it aligns with the diagnosis. Choices A, B, and D are less specific to neuroblastoma. Weight loss and listlessness (Choice A) can be nonspecific symptoms, while dark yellow urine in small amounts (Choice B) may suggest dehydration or other conditions. Muscle weakness and unsteadiness (Choice D) could point towards various neurological or muscular issues but are not as directly related to neuroblastoma as the symptom described in Choice C.

5. A healthcare provider is preparing to insert an IV catheter into a client's arm before starting IV fluid therapy. Which of the following interventions should the provider implement to prevent infection?

• A. Thread the IV catheter so that the hub rests at the insertion site
• B. Shave excess hair from around the insertion site
• C. Cleanse the site with hydrogen peroxide before IV catheter insertion
• D. Palpate the site carefully just before inserting the IV catheter

Correct answer: A

Rationale: Inserting the IV catheter so that the hub rests at the insertion site reduces the risk of contamination along the length of the catheter. This technique helps prevent introducing microbes into the bloodstream during the catheter insertion process. Shaving excess hair is unnecessary and can increase the risk of skin irritation and infection. Cleansing the site with hydrogen peroxide is outdated as it can cause tissue damage and delay wound healing. Palpating the site just before insertion can introduce bacteria from the skin surface into the insertion site, increasing the risk of infection.

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