Nursing Elites

1. Rales and rhonchi are frequently noted during an examination of lung sounds. What is the difference between the two?

• A. Rales are louder.
• B. Rhonchi are noted only in infants.
• C. Rales occur on inspiration, rhonchi on expiration.
• D. Rales are noted only in infants.

Correct answer: C

Rationale: The correct answer is that rales occur on inspiration, while rhonchi occur on expiration. Rales are typically heard during inhalation when there is fluid in the alveoli or air passages. Rhonchi, on the other hand, are caused by air passing through obstructed airways during exhalation due to secretions in the respiratory tract. Choice A is incorrect because the loudness of the sounds is not the primary distinguishing factor between rales and rhonchi. Choice B is incorrect as rhonchi can be heard in individuals beyond infancy. Choice D is incorrect as rales can be present in patients of various age groups, not just infants.

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. A small fire has erupted in a wastebasket in the client waiting room. Which of the following is the first action of the nurse?

• A. Call 9-1-1
• B. Find the fire extinguisher
• C. Move clients to safety
• D. Throw water on the fire

Correct answer: C

Rationale: When a fire starts in a healthcare setting, the first action of the nurse is to move clients and anyone who may be in danger to a safe location. Ensuring the safety of clients is the top priority during emergencies. While using a fire extinguisher could be a subsequent step to contain the fire, the immediate focus should be on evacuating individuals from harm's way. Calling 9-1-1 is important, but moving clients to safety should be the nurse's initial response. Throwing water on the fire may not be effective or safe, as it can exacerbate some types of fires.

4. When printing out an EKG, a nurse notices that the QRS complexes are extremely small. What should be the next step?

• A. Alert the physician immediately as this is a sign of impending cardiac arrest.
• B. Check to see that all leads are attached and rerun the EKG.
• C. Increase the sensitivity control to 20 mm deflection.
• D. Decrease the run speed to 50.

Correct answer: C

Rationale: Increasing the sensitivity control to 20 mm deflection will double the sensitivity, allowing for better observation of the small QRS complexes. This step is crucial in obtaining a clearer EKG reading. Choice A is incorrect because small QRS complexes do not necessarily indicate impending cardiac arrest; it's more likely a technical issue. Choice B is not the first step to take when small QRS complexes are observed; it's important to adjust the settings first. Choice D is incorrect because decreasing the run speed to 50 is not the appropriate action for this situation; adjusting the sensitivity control is more relevant to improve the visualization of the complexes.

5. A client has applied a cold pack to their arm to help decrease swelling and inflammation after an injury. Which of the following signs indicates that the cold pack should be removed?

• A. The skin on the arm appears mottled
• B. The cold pack has been in place for 10 minutes
• C. The client complains of feeling nauseated
• D. The capillary refill in the area distal to the arm is 2 seconds

Correct answer: A

Rationale: When using a cold pack for therapeutic purposes, it is essential to monitor the site to prevent tissue damage. Prolonged use of cold therapy can lead to pale, mottled skin with a bluish appearance. This change in skin color indicates poor circulation, and the cold pack should be removed immediately to prevent tissue injury. Choices B, C, and D are incorrect because the duration of cold pack application, client complaints of nausea, and capillary refill time do not specifically indicate the need for the cold pack to be removed due to potential tissue damage.

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