Nursing Elites

1. During a heritage assessment, which question is most appropriate for the nurse to ask?

• A. "Do you smoke?"?
• B. "What is your religion?"?
• C. "Do you have a history of heart disease?"?
• D. "How many years have you lived in the United States?"?

Correct answer: D

Rationale: During a heritage assessment, it is crucial for the nurse to ask questions related to a person's country of ancestry, years in the United States, cultural practices, beliefs, and values. By asking about the number of years lived in the United States, the nurse can gain insights into the individual's cultural background and heritage. Options B, C, and A are not directly related to assessing heritage. Asking about religion only addresses one aspect of heritage, while smoking history and health history do not provide a comprehensive view of a person's heritage.

2. A patient's urine tests positive for glucose. The doctor asks you to confirm this finding. Which of the following would BEST confirm this finding?

• A. Run the urine on the hand-held glucometer.
• B. Have another MA perform a repeat dipstick test.
• C. Run a Clinitest.
• D. Run an Acetest.

Correct answer: C

Rationale: To confirm glucosuria, the most appropriate method is to run a Clinitest. Clinitest tablets are specifically designed to detect glucose in urine samples. This test is particularly useful when the urine is discolored, making it challenging to accurately assess the color change.\n Choice A, using a hand-held glucometer, is not the standard method for confirming glucose in urine; these devices are primarily used for blood glucose monitoring.\n Choice B, having another Medical Assistant perform a repeat dipstick test, may not provide a more definitive confirmation as dipstick tests can sometimes yield false positives or be less accurate compared to other methods like the Clinitest.\n Choice D, running an Acetest, is used to detect ketones in the urine, not glucose. Ketones are typically associated with conditions like diabetic ketoacidosis, which is different from glucosuria.

3. In which of these patients would rectal temperatures be measured?

• A. Older adult
• B. Critically ill patient
• C. School-age child
• D. Patient receiving oxygen via nasal cannula

Correct answer: B

Rationale: Rectal temperature measurement is preferred in situations where other routes are impractical or when the most accurate measure is necessary, such as in critically ill patients. The rectal route may be chosen due to its reliability in such cases. For older adults, school-age children, and patients receiving oxygen via nasal cannula, rectal temperature measurement is not typically indicated. Other routes like oral, tympanic, or axillary measurements are more commonly used in these populations due to comfort, convenience, and non-invasive nature.

4. Which gland of the endocrine system secretes a hormone that assists with the sleep/wake cycle?

• A. Pituitary
• B. Pineal
• C. Pancreas
• D. Hypothalamus

Correct answer: B

Rationale: The correct answer is the Pineal gland. The Pineal gland, located in the brain, secretes melatonin, which plays a crucial role in regulating the sleep/wake cycle in response to exposure to light. The Pituitary gland (Choice A) secretes various hormones but not specifically related to the sleep/wake cycle. The Pancreas (Choice C) secretes insulin and digestive enzymes, not hormones related to the sleep/wake cycle. The Hypothalamus (Choice D) is involved in regulating many bodily functions, including hormone secretion, but it does not directly secrete the hormone that regulates the sleep/wake cycle.

5. The nurse receives change-of-shift report on the following four patients. Which patient should the nurse assess first?

• A. A 23-year-old patient with cystic fibrosis who has pulmonary function testing scheduled
• B. A 46-year-old patient on bed rest who is complaining of sudden onset of shortness of breath
• C. A 77-year-old patient with tuberculosis (TB) who has four antitubercular medications due in 15 minutes
• D. A 35-year-old patient who was admitted the previous day with pneumonia and has a temperature of 100.2 F (37.8 C)

Correct answer: B

Rationale: The correct answer is the 46-year-old patient on bed rest who is complaining of sudden onset of shortness of breath. Patients on bed rest who are immobile are at high risk for deep vein thrombosis (DVT). Sudden onset of shortness of breath in a patient with a DVT suggests a pulmonary embolism, which requires immediate assessment and action such as oxygen administration to maintain adequate oxygenation. The other patients should also be assessed as soon as possible, but they do not present with an immediate life-threatening condition that requires urgent intervention like the patient experiencing sudden shortness of breath.

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