Nursing Elites

1. A nurse is preparing to assess the dorsalis pedis pulse. The nurse palpates this pulse by placing the fingertips in which location?

• A. Behind the knee
• B. Lateral to the extensor tendon of the big toe
• C. In the groove between the malleolus and the Achilles tendon
• D. Below the inguinal ligament, halfway between the pubis and the anterior superior iliac spines

Correct answer: B

Rationale: The correct location to palpate the dorsalis pedis pulse is lateral to and parallel with the extensor tendon of the big toe. Choices A, C, and D describe the locations for other pulses - popliteal, posterior tibial, and femoral artery respectively. The popliteal pulse is found behind the knee, the posterior tibial pulse is located in the groove between the malleolus and the Achilles tendon, and the femoral artery is situated below the inguinal ligament, halfway between the pubis and the anterior superior iliac spines.

2. When assessing the carotid artery of a client with cardiovascular disease, what action should a nurse perform?

• A. Palpating the carotid artery in the upper third of the neck
• B. Palpating both arteries simultaneously to compare amplitude
• C. Listening to the carotid artery, using the bell of the stethoscope to assess for bruits
• D. Instructing the client to take slow, deep breaths while the nurse listens to the carotid artery

Correct answer: C

Rationale: When assessing the carotid artery of a client with cardiovascular disease, the nurse should listen to the carotid artery using the bell of the stethoscope to assess for bruits. This is crucial in detecting abnormal sounds that may indicate underlying pathology. Palpating the carotid artery in the upper third of the neck can trigger a vagal response, leading to a decrease in heart rate, which is undesirable. Palpating both arteries simultaneously can disrupt blood flow to the brain. Instructing the client to take slow, deep breaths is unnecessary and not a standard practice during carotid artery assessment.

3. The nurse is teaching parents of a newborn about feeding their infant. Which of the following instructions should the nurse include?

• A. Use the defrost setting on microwave ovens to warm bottles.
• B. When refrigerating formula, discard partially used bottles after 24 hours.
• C. When using formula concentrate, mix one part concentrate and two parts water.
• D. If a portion of one bottle is left for the next feeding, discard it.

Correct answer: B

Rationale: The correct answer is to use the defrost setting on microwave ovens to warm bottles. It is crucial to be cautious when heating bottles in a microwave to prevent milk from becoming superheated. The defrost setting is recommended, and the formula's temperature should always be checked before feeding the baby. Choice B, which advises to discard partially used bottles of refrigerated formula after 24 hours, is also correct. This is important to prevent the introduction of pathogens by the baby into the formula. Choice C, recommending mixing one part formula concentrate with two parts water, is essential for ensuring the correct dilution. Choice D, suggesting to discard any remaining portion of a bottle for the next feeding, is incorrect. It is not necessary to discard the remaining portion if it has been refrigerated promptly and used within a safe time frame. Adding fresh formula to a partially used bottle is not recommended, as it can lead to the growth of pathogens that may be transferred to the new formula.

4. A preschooler has successfully completed the test item 'counts 5 blocks' on the Denver II test. This pass is evidence of which of the following developmental concepts?

• A. centration
• B. causality
• C. nonreversibility
• D. conservation

Correct answer: D

Rationale: The ability of a preschooler to move five blocks to a piece of paper and state there are five blocks on the paper is evidence that the preschooler has the ability of conservation. This concept refers to the fact that the quantity of something doesn't change just because the shape, contour, and so on has changed. Five blocks are still five blocks, whether they are lying beside the paper, stacked on the paper, or moved to the paper. Centration is the ability to concentrate on one feature of a situation while neglecting all other aspects. Causality is based on the sequence of events, one event ordinarily following another. Non-reversibility refers to the inability of preschoolers to reverse their operations. They are only able to think forward, not retrace or reverse their thought processes.

5. A nurse is preparing to auscultate a fetal heart rate (FHR). The nurse performs the Leopold maneuvers to determine the position of the fetus and then places the fetoscope over which part of the fetus?

• A. Back of the fetus
• B. Carotid artery in the neck of the fetus
• C. Brachial area of one extremity of the fetus
• D. Chest of the fetus

Correct answer: A

Rationale: The nurse would use the Leopold maneuvers to identify the position of the fetus and determine the location of the fetal back. The fetal heart rate (FHR) is most easily heard through the fetal back because it usually lies closest to the surface of the maternal abdomen. Auscultation of the FHR over the chest, carotid artery, or brachial area is not possible due to the fetal position within the maternal abdomen. Placing the fetoscope over the carotid artery or brachial area would not yield the fetal heart rate, and the chest area is not typically used for auscultating the FHR.

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