Nursing Elites

1. A physician's order instructs a nurse to take a temperature at the axilla. Where would the nurse place the thermometer?

• A. In the rectum
• B. In the mouth
• C. On the temples
• D. In the armpit

Correct answer: A

Rationale: When a physician's order specifies taking a temperature at the axilla, the nurse should place the thermometer in the armpit. The axilla is the anatomical area of the armpit located under the arms, proximal to the trunk. Placing the thermometer in the rectum (Choice A) is used for rectal temperature measurements, in the mouth (Choice B) for oral temperature measurements, and on the temples (Choice C) is not a common site for temperature assessment. Therefore, the correct placement based on the given instruction is in the armpit.

2. What is the most effective step in hand washing?

• A. Using friction to remove potential pathogens.
• B. Using hospital-grade soap.
• C. Moisturizing the hands after washing to prevent cracking.
• D. Washing hands with soap for at least 15 seconds.

Correct answer: A

Rationale: The most effective step in hand washing is using friction to remove potential pathogens. While using soap, moisturizing hands, and washing for a sufficient duration are important aspects of hand hygiene, the mechanical action of rubbing hands together with friction is crucial in dislodging and removing dirt, debris, and potential pathogens. Hospital-grade soap may be beneficial, but the physical act of friction is key to effective hand washing. Moisturizing after washing is important for skin health but not the most effective step in the hand washing process. Simply washing hands for a specific duration, such as 15 seconds, without proper friction may not effectively remove contaminants. Therefore, using friction for thorough cleaning is the most crucial step in hand washing.

3. What is the primary purpose of a patient care meeting or conference?

• A. the patient's ability to pay for the costs of their care
• B. how the healthcare team can best meet the patient's needs
• C. the patient's physical status and condition
• D. the patient's psychosocial status and condition

Correct answer: B

Rationale: The primary purpose of a patient care meeting or conference is to determine how the healthcare team can best meet the patient's needs. These meetings involve discussions among healthcare professionals to tailor the care plan to the specific needs and preferences of the patient. Option A is incorrect because financial discussions are generally not the primary focus of patient care meetings. Option C is incorrect as the patient's physical status is usually already known and is not the primary purpose of the meeting. Option D is incorrect as psychosocial aspects, while important, are not the sole focus of the meeting, which is primarily about addressing the patient's overall needs and preferences.

4. To accurately assess a patient's respiration rate, which of the following methods would be BEST?

• A. Tell the patient, 'Please remain silent while I count your number of breaths.'
• B. Count respirations at the same time you are counting the pulse rate
• C. Count the pulse rate for one minute, then, while keeping your index fingers on the patient's radial artery, count the respirations for an additional minute.
• D. Count the patient's respiration rate, then take the patient's temperature, and then take the pulse rate.

Correct answer: B

Rationale: The most accurate method to assess a patient's respiration rate is to count the breaths simultaneously while counting the pulse rate. This approach ensures that the patient is unaware of the specific focus on their breathing, preventing any conscious alteration in breathing patterns. Choice A is incorrect because informing the patient may lead to altered breathing as the patient may consciously change their breathing pattern. Choice C involves counting the pulse rate first, which is not necessary for assessing respiration rate. Choice D is incorrect as it includes unnecessary steps such as taking the patient's temperature before counting respiration rate, which adds no value to accurately assessing the respiration rate.

5. During the general survey, what action is a component of the assessment?

• A. Observing the patient's body stature and nutritional status
• B. Interpreting the subjective information reported by the patient
• C. Measuring the patient's temperature, pulse, respirations, and blood pressure
• D. Observing specific body systems during the physical assessment

Correct answer: A

Rationale: During the general survey, the nurse assesses the patient's overall appearance, body structure, mobility, and behavior, which includes observing body stature and nutritional status. Interpreting subjective information reported by the patient is part of the subjective data collection process and not the general survey. Measuring vital signs like temperature, pulse, respirations, and blood pressure is part of a focused physical examination, not the general survey. Additionally, observing specific body systems while performing a physical assessment is more specific and focused than the general survey.

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