Nursing Elites

1. A patient's urine specimen tested positive for bilirubin. Which of the following is most true?

• A. The patient should be evaluated for kidney disease
• B. The specimen was probably left at room temperature for more than two hours
• C. The specimen is positive for bacteria
• D. The specimen should be stored in an area protected from light

Correct answer: D

Rationale: Bilirubin is easily broken down by light, so all samples testing positive for bilirubin should be protected from light exposure. Storing the specimen in an area protected from light helps maintain the integrity of the bilirubin levels for accurate testing. Choice A is incorrect because the presence of bilirubin in urine does not necessarily indicate kidney disease. Choice B is incorrect as the exposure to light, not room temperature, affects bilirubin levels. Choice C is incorrect as the presence of bilirubin does not indicate the presence of bacteria in the specimen.

2. An examiner is using an ophthalmoscope to examine a patient's eyes. The patient has astigmatism and is nearsighted. Which of these techniques by the examiner would indicate that the examination is being correctly performed?

• A. Rotating the lens selector dial to bring the object into focus
• B. Using the large full circle of light when assessing pupils that are not dilated
• C. Rotating the lens selector dial to the black numbers to compensate for astigmatism
• D. Using the grid on the lens aperture dial to visualize the external structures of the eye

Correct answer: A

Rationale: To correctly perform an eye examination using an ophthalmoscope on a patient with astigmatism and nearsightedness, the examiner should rotate the lens selector dial to bring the object into focus. This adjustment helps compensate for nearsightedness or farsightedness but does not correct astigmatism. Rotating the lens selector dial to the black numbers is not an appropriate technique for compensating for astigmatism. Using the grid on the lens aperture dial is primarily for visualizing external structures of the eye, not for addressing refractive errors. The large full circle of light is typically used when assessing dilated pupils, not for examining patients with astigmatism and nearsightedness. Therefore, the correct technique is rotating the lens selector dial to bring the object into focus.

3. When teaching a patient to use the three-point gait technique of crutch use:

• A. The injured leg moves ahead at the same time as both crutches.
• B. One crutch moves at a time and is then followed by the injured leg.
• C. Both crutches move ahead at the same time followed by both legs at the same time.
• D. None of the above are correct.

Correct answer: A

Rationale: The correct technique for a three-point gait involves the injured leg moving simultaneously with both crutches, followed by the uninjured leg. This gait pattern is utilized when the patient is unable to bear full weight on one of their legs. Choice A accurately describes the appropriate sequence of movements for the three-point gait technique. Choices B and C do not accurately reflect the correct pattern of movement during the three-point gait technique, making them incorrect. Choice D is incorrect as there is a correct option among the choices provided.

4. Which of the following descriptors is most appropriate to use when stating the 'problem' part of a nursing diagnosis?

• A. Grimacing
• B. Anxiety
• C. Oxygenation saturation 93%
• D. Output 500 mL in 8 hours

Correct answer: B

Rationale: The problem part of a nursing diagnosis in the context of nursing care plans should focus on the client's response to a life process, event, or stressor. This response is what is used to identify the nursing diagnosis. 'Anxiety' is the most appropriate descriptor for the problem part of a nursing diagnosis as it reflects a psychological response that can be addressed by nursing interventions. 'Grimacing' is a physical manifestation and not the problem itself. 'Oxygenation saturation 93%' and 'Output 500 mL in 8 hours' are data points or cues that a nurse would use to formulate the nursing diagnostic statement, not the actual problem being addressed.

5. When percussing over the lungs of a 4-year-old child, the nurse hears bilateral loud, long, and low tones. How should the nurse proceed?

• A. Palpate over the area for increased pain and tenderness.
• B. Ask the child to take shallow breaths and percuss over the area again.
• C. Refer the child to a specialist because of an increased amount of air in the lungs.
• D. Consider this finding as normal for a child this age and proceed with the examination.

Correct answer: D

Rationale: In pediatric patients, loud, long, and low tones heard when percussing over the lungs are normal findings. These percussion notes are characteristic of a child's lung due to its thin chest wall and increased air content. It is unnecessary to palpate for pain and tenderness, ask the child to take shallow breaths and repeat the percussion, or refer the child to a specialist. Therefore, the correct action is to consider these findings as normal for the child's age and continue with the examination.

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