Nursing Elites

1. The nurse is assessing the vital signs of a 3-year-old patient who appears to have an irregular respiratory pattern. How would the nurse assess this child's respirations?

• A. Respirations should be counted for 1 full minute.
• B. Child's pulse and respirations should be simultaneously checked for 30 seconds and then multiplied by 2.
• C. Child's respirations should be checked for a minimum of 5 minutes to identify any variations in his or her respiratory pattern.
• D. Patient's respirations should be counted for 15 seconds and then multiplied by 4.

Correct answer: A

Rationale: To accurately assess a child's respiratory pattern, the nurse should count respirations for a full minute. This duration provides a comprehensive view of the child's breathing pattern, ensuring abnormalities are not missed. Counting for only 30 seconds may not capture irregularities effectively. Checking respirations for 5 minutes is excessive and unnecessary for a routine assessment. Counting for 15 seconds and multiplying by 4 is not as precise as a full-minute count. Pulse and respirations should not be checked simultaneously; instead, the nurse should count respirations unobtrusively while appearing to take the child's pulse. Therefore, the correct approach is to count the child's respirations for 1 full minute to obtain an accurate assessment.

2. You are ready to wash your patient's face. You would start by washing what area of the face?

• A. The forehead
• B. The eyes
• C. The ears
• D. The cheeks

Correct answer: B

Rationale: When washing a patient's face, it is essential to start by cleaning the eyes. The eye area is considered the priority because moving from an area that can potentially be infected to areas of the face and body that are least able to become infected with a washcloth helps prevent the spread of germs. Washing the forehead, ears, or cheeks before the eyes may risk transferring bacteria to a more sensitive area like the eyes, which could lead to infections or other complications. Therefore, starting with the eyes ensures proper hygiene and reduces the risk of introducing harmful microorganisms to the patient's face.

3. The most accurate reading for a temperature is done:

• A. Orally
• B. Aurally through a clean canal
• C. Rectally
• D. Axially

Correct answer: B

Rationale: Aural readings are done through the ear canal. The tympanic membrane shares a blood supply with the hypothalamus, the brain area that regulates body temperature. Taking the temperature aurally through a clean canal ensures an accurate reading. Choice A (Orally) is not the most accurate method for temperature measurement as it can be affected by external factors like drinking hot or cold liquids. Choice C (Rectally) is invasive and less practical for routine temperature monitoring. Choice D (Axially) is not a standard method for temperature measurement and may not provide accurate results.

4. What technique would the nurse use to accurately assess a rectal temperature in an adult?

• A. Use a lubricated blunt tip thermometer.
• B. Insert the thermometer 2 to 3 inches into the rectum.
• C. Leave the thermometer in place for up to 8 minutes if the patient is febrile.
• D. Wait 2 to 3 minutes if the patient has recently smoked a cigarette.

Correct answer: A

Rationale: To accurately assess a rectal temperature in an adult, a nurse should use a lubricated rectal thermometer with a short, blunt tip. The thermometer is inserted only 2 to 3 cm (1 inch) into the rectum and left in place for 2 minutes. Choice B is incorrect as inserting the thermometer 2 to 3 inches would be too deep and inaccurate. Choice C is incorrect as leaving the thermometer in place for up to 8 minutes is unnecessary and can cause discomfort. Choice D is incorrect as smoking a cigarette does not impact rectal temperatures.

5. Which practice will help reduce the risk of a needlestick injury?

• A. Expose the end of the needle only when ready to enter the room for the procedure
• B. Never recap a needle after use
• C. Keep a sharps container nearby where it can be easily accessed
• D. Exchange needles from a central area rather than passing them between workers

Correct answer: C

Rationale: To reduce the risk of a needlestick injury, it is essential to keep a sharps container nearby where it can be easily accessed. This practice ensures quick and safe disposal of needles after use, minimizing the chances of accidental needlesticks. Recapping needles should be avoided as it increases the risk of injuries. Passing needles between workers should also be avoided to prevent accidental needle pricks during handovers. Therefore, the best practice to prevent needlestick injuries is to maintain a sharps container nearby for safe and immediate disposal of needles.

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