Nursing Elites

1. What is the BEST blood collection location for a newborn?

• A. the AC
• B. the veins of the forehead
• C. the heel
• D. the fingertips

Correct answer: C

Rationale: When collecting blood from newborns, it is safest and most commonly done by collecting blood from the lateral or medial aspect of the baby's heel. This location is preferred due to the accessibility of the veins and the minimal discomfort caused to the newborn. Veins in the forehead are not commonly used for blood collection in newborns. The fingertips are not optimal for blood collection in newborns due to their small size and the potential for causing discomfort. The AC (antecubital) area, typically used in adults for blood collection, is not recommended for newborns due to the size of their veins and the potential risk of injury.

2. The healthcare provider is examining a patient who is reporting "feeling cold."? Which is a mechanism of heat loss in the body?

• A. Exercise
• B. Radiation
• C. Metabolism
• D. Food digestion

Correct answer: B

Rationale: When the body needs to lose heat, one of the mechanisms it employs is radiation. Radiation involves the transfer of heat from the body to the environment in the form of infrared waves. While metabolism, exercise, and food digestion contribute to heat production, they are not mechanisms for heat loss. Metabolism generates heat as a byproduct, exercise increases metabolic rate leading to heat production, and food digestion involves some heat generation, but these processes do not directly facilitate heat loss. Therefore, in the scenario where the patient is feeling cold, radiation is the primary mechanism for the body to lose excess heat and maintain a stable internal temperature.

3. You have been asked to record the amount of food that the person has eaten during each meal. What kinds of words or numbers would you use to record this food intake?

• A. A little, a moderate amount, or all of the meal
• B. 50 cc, 100 cc, or 500 cc of the meal
• C. 25%, 50%, or 100% of the meal
• D. Either A or C

Correct answer: C

Rationale: Food intake is typically measured in terms of the percentage (%) of food that has been eaten. Using percentages allows for a more precise and standardized way of recording food consumption. For instance, you would record 25% of the vegetable if the person has eaten about a quarter of the vegetables on the plate. Choices A and B are incorrect. Choice A's terms 'a little' and 'a moderate amount' are vague and not specific enough for accurate documentation. Choice B's use of cc is more appropriate for measuring fluids, not solid foods. Choice D is also incorrect as it combines vague terms with percentages, which could lead to confusion in accurately documenting the food intake.

4. What type of blood pressure measurement error is most likely to occur if the nurse does not check for the presence of an auscultatory gap?

• A. Diastolic blood pressure may not be heard.
• B. Diastolic blood pressure may be falsely low.
• C. Systolic blood pressure may be falsely low.
• D. Systolic blood pressure may be falsely high.

Correct answer: C

Rationale: If an auscultatory gap is undetected, a falsely low systolic reading may occur. This gap can lead to an underestimation of the systolic blood pressure, causing potential misinterpretation of the patient's condition. The diastolic blood pressure may not be heard due to the gap, but the critical issue in this scenario is the risk of underestimating systolic blood pressure, which can impact clinical decision-making. Choices B, C, and D are incorrect because the key concern in this context is the potential for a falsely low systolic blood pressure reading when an auscultatory gap is not assessed.

5. When performing a physical examination, safety must be considered to protect the examiner and the patient against the spread of infection. Which of these statements describes the most appropriate action the nurse would take when performing a physical examination?

• A. Washing one's hands after removing gloves is necessary, even if the gloves are still intact
• B. Hands are washed before and after every physical patient encounter
• C. Hands are washed before the examination of each body system to prevent the spread of bacteria from one part of the body to another
• D. Gloves are worn throughout the entire examination to demonstrate concern regarding the spread of infectious diseases

Correct answer: B

Rationale: The most appropriate action for the nurse to take when performing a physical examination is to wash their hands before and after every physical patient encounter. This practice helps prevent the spread of infection. Hands should also be washed after contact with blood, body fluids, secretions, and excretions, and after contact with any equipment contaminated with body fluids. It is crucial to wash hands after removing gloves, even if the gloves appear intact. Choice A is incorrect because washing hands after removing gloves is necessary to ensure thorough hygiene. Choice C is incorrect because hands should be washed before and after every patient encounter, not just before examining each body system. Choice D is incorrect because gloves should be worn when there is potential contact with body fluids, but they do not need to be worn throughout the entire examination.

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