Nursing Elites

1. Your patient ate an 8-ounce cup of Italian ice. How much will you record on the patient's Intake and Output form in terms of this patient's fluid intake?

• A. 240 cc
• B. 120 cc
• C. 8 cc
• D. 0 cc because Italian ice is not a fluid

Correct answer: A

Rationale: The correct answer is 240 cc. Italian ice is considered a fluid, so you would record the intake of 240 cc. Choice B (120 cc) and Choice C (8 cc) are incorrect as they do not reflect the correct amount of fluid intake from an 8-ounce cup of Italian ice. Choice D (0 cc) is incorrect because Italian ice does count as a fluid intake and should be recorded as such.

2. Which of the following is classified as a prerenal condition that affects urinary elimination?

• A. Nephrotoxic medications
• B. Pericardial tamponade
• C. Neurogenic bladder
• D. Polycystic kidney disease

Correct answer: B

Rationale: A prerenal condition is one that causes reduced urinary elimination by affecting the blood flow to the kidneys. Pericardial tamponade is a condition that impacts the heart's ability to pump sufficient blood, leading to decreased blood flow to vital organs such as the kidneys. This reduction in blood flow to the kidneys can result in decreased urine production. The other choices, such as nephrotoxic medications, neurogenic bladder, and polycystic kidney disease, do not primarily affect the blood flow to the kidneys and are not classified as prerenal conditions that impact urinary elimination.

3. The nurse is unable to palpate the right radial pulse on a patient. What would the nurse do next?

• A. Auscultate over the area with a fetoscope.
• B. Use a goniometer to measure the pulsations.
• C. Use a Doppler device to check for pulsations over the area.
• D. Check for the presence of pulsations with a stethoscope.

Correct answer: C

Rationale: When a nurse is unable to palpate a radial pulse, the next step is to use a Doppler device to check for pulsations over the area. Doppler devices are specifically designed to augment pulse or blood pressure measurements. Auscultating with a fetoscope is used to listen to fetal heart tones and is not relevant in this scenario. Goniometers are used to measure joint range of motion and are not used to assess pulses. Stethoscopes are primarily used to auscultate breath, bowel, and heart sounds, not to check for pulsations in peripheral pulses. Therefore, the correct course of action when unable to palpate a pulse is to utilize a Doppler device to assess for pulsations in the radial pulse area.

4. Madge is a 91-year-old nursing home resident with a history of dementia and atrial fibrillation who has been admitted to the hospital for treatment of pneumonia. As you are performing her bed bath, you note bruising around her breasts and genital area. What potential issue should be of major concern in Madge's situation?

• A. Idiopathic thrombocytopenic purpura (ITP)
• B. Embolic stroke
• C. Sexual abuse
• D. Nursing home-acquired pneumonia (NHAP)

Correct answer: C

Rationale: Bruising around the breasts and genitals should trigger concern for sexual abuse. Elder abuse is a growing problem in America, and nurses are uniquely positioned to recognize and intervene on behalf of vulnerable populations, such as the elderly. According to the National Center on Elder Abuse (NCEA), major types of elder abuse include physical abuse, sexual abuse, emotional or psychological abuse, neglect, abandonment, financial or material exploitation, and self-neglect. In this scenario, given Madge's age, history of dementia, and the presence of unexplained bruising in sensitive areas, sexual abuse must be considered as a major concern. Idiopathic thrombocytopenic purpura (ITP) is a platelet disorder that presents with excessive bruising and bleeding, but it is less likely in this case as the bruising pattern is suggestive of a different cause. Embolic stroke is a neurological condition that typically presents with sudden onset neurological deficits and is not related to the observed bruising. Nursing home-acquired pneumonia (NHAP) is a common issue in elderly residents but would not manifest as bruising in specific areas like the breasts and genitals.

5. After a class on culture and ethnicity, the new graduate nurse reflects a correct understanding of the concept of ethnicity with which statement?

• A. "Ethnicity is dynamic and ever-changing."?
• B. "Ethnicity is the belief in a higher power."?
• C. "Ethnicity pertains to a social group that may possess shared traits such as religion and language."?
• D. "Ethnicity is learned from birth through the processes of language acquisition and socialization."?

Correct answer: C

Rationale: Ethnicity pertains to a social group that may possess shared traits such as common geographic origin, migratory status, religion, language, values, traditions, or symbols and food preferences. Culture is dynamic, ever-changing, and learned from birth through the processes of language acquisition and socialization. Religion is the belief in a higher power. Ethnicity pertains to a social group within the social system that claims to have variable traits, such as a common geographic origin, migratory status, religion, race, language, values, traditions, symbols, or food preferences.

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