Nursing Elites

1. What term is used to describe the process of preparing the bed with a new set of linens?

• A. Bed bath
• B. Bed making
• C. Bed shampoo
• D. Bed lining

Correct answer: B

Rationale: The correct answer is 'Bed making.' Bed making is the term used to describe the process of preparing the bed with a new set of linens. This includes changing the sheets, pillowcases, and adding any additional bedding to make the bed clean, fresh, and comfortable for the next use. 'Bed bath' is typically associated with washing a patient in bed, 'Bed shampoo' is not a common term related to bed preparation, and 'Bed lining' does not accurately describe the process of changing linens on a bed.

2. Palpating the midclavicular line is the correct technique for assessing

• A. Baseline vital signs
• B. Systolic blood pressure
• C. Respiratory rate
• D. Apical pulse

Correct answer: D

Rationale: Palpating the midclavicular line is the correct technique for assessing the apical pulse. The apical pulse is located at the point of maximal impulse (PMI), which is typically at the fifth intercostal space at the midclavicular line. This technique allows healthcare providers to accurately assess the heart rate and rhythm by listening to the heart sounds directly at this point.

3. To assess the kidney function of a patient with an indwelling urinary (Foley) catheter, the nurse measures the hourly urine output. When should she notify the physician?

• A. Less than 30 ml/hour
• B. 64 ml in 2 hours
• C. 90 ml in 3 hours
• D. 125 ml in 4 hours

Correct answer: A

Rationale: Notifying the physician is necessary when the urine output is less than 30 ml/hour as it indicates impaired kidney function. Adequate urine output is essential for monitoring kidney function, and a urine output less than 30 ml/hour could suggest potential renal issues that require medical attention.

4. A client had oral surgery following a motor vehicle accident. The nurse assessing the client finds the skin flushed and warm. Which of the following would be the best method to take the client’s body temperature?

• A. Oral
• B. Axillary
• C. Arterial line
• D. Rectal

Correct answer: D

Rationale: In cases where the oral route is contraindicated due to oral surgery or altered consciousness, the rectal method is preferred for the most accurate body temperature reading. This method is particularly useful when the skin is flushed and warm, as it provides a reliable reflection of core body temperature despite external factors affecting the skin temperature. Axillary temperature may not be as accurate as rectal temperature due to variations caused by environmental factors and technique. Arterial line temperature monitoring is invasive and not typically used for routine temperature assessment.

5. A healthcare professional is assessing a client who has experienced a left-hemispheric stroke. Which of the following is an expected finding?

• A. Impulse control difficulty
• B. Poor judgement
• C. Inability to recognize familiar objects
• D. Loss of depth perception

Correct answer: C

Rationale: Patients who have experienced a left-hemispheric stroke may exhibit symptoms of agnosia, which is the inability to recognize familiar objects or people. This occurs due to damage to the right hemisphere of the brain, which is responsible for visual and spatial perception. Impulse control difficulty, poor judgment, and loss of depth perception are not typically associated with left-hemispheric strokes.

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