Nursing Elites

1. During the examination, it is often appropriate to offer some brief teaching about the patient's body or the examiner's findings. Which one of these statements by the nurse is most appropriate?

• A. "Your atrial dysrhythmias are under control."?
• B. "You have pitting edema and mild varicosities."?
• C. "Your pulse is 80 beats per minute, which is within the normal range."?
• D. "I'm using my stethoscope to listen for any crackles, wheezes, or rubs in your lungs."?

Correct answer: C

Rationale: During an examination, providing brief educational information to the patient can enhance rapport, as long as the patient can comprehend the terminology. The most appropriate statement from the nurse is "Your pulse is 80 beats per minute, which is within the normal range." This statement conveys a vital sign in a way that is likely understandable to the patient. Choices A, B, and D use terminology that may be unfamiliar or confusing to the patient. Option A mentions 'atrial dysrhythmias,' which might not be clear to the patient. Option B involves terms like 'pitting edema' and 'varicosities,' which could be unfamiliar to the patient. Option D references 'crackles,' 'wheezes,' and 'rubs,' which might not be easily understood by the patient.

2. When measuring the vital signs of a 6-month-old infant, which action by the nurse is correct?

• A. Respirations are measured first, followed by pulse and temperature.
• B. Vital signs should be measured as frequently as in an adult.
• C. Procedures are explained to the parent, and the infant is encouraged to handle the equipment.
• D. The nurse should first measure the infant's vital signs before performing a physical examination.

Correct answer: A

Rationale: When assessing vital signs in a 6-month-old infant, the correct order is to measure respirations first, followed by pulse and temperature. This sequence is important to avoid potential alterations in respiratory and pulse rates caused by factors like crying or discomfort. Measuring the temperature first, especially rectally, may lead to an increase in respiratory and pulse rates, which can skew the results. It is crucial to follow this specific order to obtain accurate baseline values. Therefore, option A is the correct choice. Option B is incorrect as the frequency of measuring vital signs in infants differs based on individual needs rather than being consistently more frequent than in adults. Option C is not directly related to the correct sequence for measuring vital signs in infants. Option D is incorrect because the physical examination typically follows the assessment of vital signs in clinical practice.

3. The nurse should wash from the ________________________ when washing a patient's eye area.

• A. outer canthus to the inner canthus
• B. inner canthus to the outer canthus
• C. internal nares to the external nares
• D. external nares to the internal nares

Correct answer: B

Rationale: When washing a patient's eye area, it is important to start from the inner canthus (closest to the nose) and move towards the outer canthus. This direction prevents any contaminants or debris from the outer area of the eye from moving towards the inner, more sensitive area. Choices C and D are incorrect as they pertain to the nasal passages (nares), which are not relevant when washing the eye area.

4. 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.

5. Specific gravity in urinalysis:

• A. compares the concentration of urine to that of distilled water
• B. is useless when the patient is dehydrated
• C. can only be measured using a refractometer
• D. None of the above

Correct answer: A

Rationale: Specific gravity in urinalysis measures the concentration of solutes in urine compared to that of distilled water. This comparison helps in assessing the kidney's ability to concentrate urine properly. It is a valuable test even in dehydrated patients as it provides insights into renal function. Specific gravity can be measured using various methods, including a refractometer or reagent strips. Normal specific gravity readings of human urine typically range from 1.005 to 1.030. Choice A is correct as it accurately describes the purpose of specific gravity in urinalysis. Choices B and C are incorrect as specific gravity remains relevant in dehydrated patients and can be measured using different techniques, not solely a refractometer.

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