Nursing Elites

1. Before administering the hepatitis B vaccine to a newborn infant, what should the nurse do?

• A. Request parental consent to administer the vaccine.
• B. Check the infant for jaundice.
• C. Check the infant's temperature.
• D. Obtain parental consent to administer the vaccine.

Correct answer: Obtain parental consent to administer the vaccine

Rationale: Before administering the hepatitis B vaccine to a newborn infant, the nurse must obtain parental consent. Hepatitis B vaccine is typically given at birth, 1 month, and 6 months of age. Checking the infant for jaundice, checking the temperature, and requesting a hepatitis blood screen are unnecessary in this context. Parental consent is crucial for any medical intervention involving minors.

2. If Ms. Barrett’s distance vision is 20/30, which of the following statements is true?

• A. The client can read from 20' what a person with normal vision can read at 30'.
• B. The client can read from 30' what a person with normal vision can read at 20'.
• C. The client can read the entire chart from 30'.
• D. The client can read the chart from 20' with the left eye and from 30' with the right eye.

Correct answer: The client can read from 20' what a person with normal vision can read at 30'.

Rationale: When Ms. Barrett's distance vision is measured as 20/30, it means that she can read from 20 feet away what a person with normal vision can read at 30 feet. The numerator (20) represents the distance in feet between the chart and the client, while the denominator (30) indicates the distance at which a normal eye can read the chart. In this case, Ms. Barrett's vision is slightly worse than normal, as she needs to be closer to the chart to read it clearly. Therefore, choice A is correct. Choices B, C, and D are incorrect: Choice B reverses the distances, Choice C assumes the client can read the entire chart from 30 feet, and Choice D introduces information not related to the 20/30 measurement.

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: Placing a tape measure around the widest point of the lower leg

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. The nurse has a client who is being transferred to another floor right around change of shift. Which of the following actions is least appropriate?

• A. Inform the staff on the other floor of any unresolved issues with the client.
• B. Ask the charge nurse if overtime would be permitted to complete the client’s transfer to the other floor.
• C. Ask the new nurse to take care of the transfer since the client’s medical record has all of the information, and a report should not be needed.
• D. Complete the transfer paperwork before the client is transferred.

Correct answer: Ask the new nurse to take care of the transfer since the client’s medical record has all of the information, and a report should not be needed.

Rationale: The least appropriate action in this scenario is to ask the new nurse to take care of the transfer without providing a full handoff of care. It is crucial to ensure a safe handoff during the transfer to maintain continuity of care and patient safety. Informing the staff on the other floor of any unresolved issues with the client (Choice A) is important for the client's well-being as it helps in providing comprehensive care. Asking the charge nurse about overtime (Choice B) demonstrates consideration for completing the task effectively, but it should not take precedence over ensuring a proper handoff. Completing the transfer paperwork before the client is transferred (Choice D) is necessary to ensure all documentation is in order, but it should be done in conjunction with providing a thorough handoff of care to the new nurse.

5. A client with an ileus is placed on intestinal tube suction. Which of the following electrolytes is lost with intestinal suction?

• A. calcium
• B. magnesium
• C. potassium
• D. sodium chloride

Correct answer: D

Rationale: The correct answer is sodium chloride. Duodenal intestinal fluid is rich in potassium (K+), sodium (Na+), and bicarbonate. When suctioning is used to remove excess fluids due to ileus, it results in the loss of sodium chloride (NaCl) leading to decreased sodium (Na+) levels. Choices A, B, and C are incorrect because calcium, magnesium, and potassium are not typically lost in significant amounts through intestinal tube suction in the context of treating ileus.

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