Nursing Elites

1. The nurse is preparing to examine a 4-year-old child. Which action by the nurse is appropriate for this age group?

• A. Explain the procedures briefly to alleviate the child's anxiety.
• B. Give the child feedback and reassurance during the examination.
• C. Ask the child to undress as needed for the examination.
• D. Perform an examination of the head last.

Correct answer: B

Rationale: For a 4-year-old child, short and simple explanations should be provided to avoid overwhelming the child. It is important to give feedback and reassurance during the examination to create a comforting environment for the child. Asking the child to undress as needed is appropriate for a thorough examination, as children at this age are usually willing to do so. Performing an examination of the head last allows the child to become more comfortable during the assessment. Therefore, the most appropriate action for a 4-year-old child is to provide feedback and reassurance during the examination, ensuring a positive experience for the child.

2. A triage nurse has four clients arrive in the emergency department within 15 minutes. Which client should the triage nurse send back to be seen first?

• A. A 2-month-old infant with a history of rolling off the bed and having a bulging fontanelle with crying
• B. A teenager who suffered singed facial hair while camping
• C. An elderly client with complaints of frequent liquid brown-colored stools
• D. A middle-aged client with intermittent pain behind the right scapula

Correct answer: B

Rationale: The correct answer is the teenager who suffered singed facial hair while camping. This client is in the greatest danger with a potential risk of respiratory distress. Singed facial hair indicates exposure to heat or fire in close range, which could have caused serious damage to the interior of the lungs. It's crucial to prioritize this client as the interior lining of the lungs has no nerve fibers, so swelling may not be immediately noticeable. The other choices, while concerning, do not present an immediate life-threatening situation. The infant's condition may be serious but does not pose an immediate danger of respiratory distress. The elderly client's symptoms could indicate gastrointestinal issues, which are important but not as urgent as potential respiratory compromise. The middle-aged client's pain behind the right scapula, while uncomfortable, does not indicate an acute life-threatening condition requiring immediate attention.

3. The abbreviation ac is defined as _____________.

• A. before the meal
• B. with the meal
• C. after the meal
• D. ante cibum

Correct answer: A

Rationale: The correct answer is 'before the meal.' The abbreviation 'ac' is derived from the Latin term 'ante cibum,' which translates to 'before a meal.' Choices B, C, and D are incorrect because 'ac' does not refer to 'with the meal,' 'after the meal,' or 'ante corpis.' It specifically denotes something occurring before a meal, making option A the correct choice in this context.

4. During an examination, a nurse notices a draining ulceration on a patient's lower leg. What is the most appropriate action in this situation?

• A. Wash hands and then contact the physician.
• B. Continue to examine the ulceration and then wash hands.
• C. Wash hands, put on gloves, and continue with the examination of the ulceration.
• D. Wash hands, proceed with the rest of the physical examination, and perform the examination of the leg ulceration last.

Correct answer: C

Rationale: In this scenario, the most appropriate action is to wash hands, put on gloves, and then continue examining the ulceration. Wearing gloves is crucial when there is a possibility of contact with body fluids, as in the case of a draining ulceration. Contacting the physician is not necessary at this point; the immediate focus should be on proper infection control by washing hands and wearing gloves. Changing the order of the examination is not recommended as it is important to follow a systematic approach to avoid missing any crucial assessments.

5. Which of these actions illustrates the correct technique for a nurse when assessing oral temperature with a glass thermometer?

• A. Wait 30 minutes if the patient has ingested hot or iced liquids.
• B. Leave the thermometer in place for 3 to 4 minutes if the patient is afebrile.
• C. Shake the glass thermometer down to 35.5°C before taking the patient's temperature.
• D. Place the thermometer at the base of the tongue and ask the patient to close his or her lips.

Correct answer: B

Rationale: The correct technique for assessing oral temperature with a glass thermometer involves leaving the thermometer in place for 3 to 4 minutes if the patient is afebrile and up to 8 minutes if the patient is febrile. Waiting 30 minutes if the patient has ingested hot or iced liquids is incorrect; instead, the nurse should wait 15 minutes in such cases. Shaking the glass thermometer down to 35.5°C, not 37.5°C, is the correct procedure before taking the patient's temperature. Placing the thermometer at the base of the tongue, not the front, and asking the patient to close their lips is the proper way to position the thermometer. Therefore, the correct answer is to leave the thermometer in place for 3 to 4 minutes if the patient is afebrile and up to 8 minutes if the patient is febrile.

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