Nursing Elites

1. The nurse is preparing to examine a 6-year-old child. Which action is most appropriate?

• A. The child is asked to undress from the waist up.
• B. The head is examined before the thorax, abdomen, and genitalia.
• C. The nurse should keep in mind that a child at this age will have a sense of modesty.
• D. Talking about the equipment being used is avoided to prevent increasing the child's anxiety.

Correct answer: C

Rationale: When examining a 6-year-old child, it is important to consider their sense of modesty. The child should undress themselves, leaving underpants on and using a gown or drape to maintain privacy. Additionally, a school-age child like a 6-year-old is curious about how equipment works, so it is beneficial to explain the purpose and function of the tools being used. The examination sequence should typically progress from the child's head to the toes to ensure a thorough assessment. Therefore, choices A, B, and D are incorrect as they do not align with the appropriate approach to examining a 6-year-old child.

2. A 70-year-old man has a blood pressure of 150/90 mm Hg in a lying position, 130/80 mm Hg in a sitting position, and 100/60 mm Hg in a standing position. How should the nurse evaluate these findings?

• A. These readings are a normal response and attributable to changes in the patient's position.
• B. The change in blood pressure readings is called orthostatic hypotension.
• C. The blood pressure reading in the lying position is within normal limits.
• D. The change in blood pressure readings is considered within normal limits for the patient's age.

Correct answer: B

Rationale: The correct answer is, 'The change in blood pressure readings is called orthostatic hypotension.' Orthostatic hypotension is defined as a drop in systolic pressure of �20 mm Hg or �10 mm Hg drop in diastolic pressure that occurs with a quick change to a standing position. This condition is common in individuals on prolonged bed rest, older adults, those with hypovolemia, or taking specific medications. The blood pressure readings provided in the question (150/90 mm Hg lying, 130/80 mm Hg sitting, and 100/60 mm Hg standing) demonstrate a significant change in blood pressure with position changes, which is indicative of orthostatic hypotension. Choices A, C, and D are incorrect because the readings do not indicate a normal response or blood pressure within normal limits for the patient's age; rather, they suggest the presence of orthostatic hypotension.

3. The nurse is taking an initial blood pressure reading on a 72-year-old patient with documented hypertension. How should the nurse proceed?

• A. Cuff should be placed on the patient's arm and inflated 30 mm Hg above the point at which the palpated pulse disappears.
• B. Cuff should be inflated to 200 mm Hg in an attempt to obtain the most accurate systolic reading.
• C. Cuff should be inflated 30 mm Hg above the patient's pulse rate.
• D. After confirming the patient's previous blood pressure readings, the cuff should be inflated 30 mm Hg above the highest systolic reading recorded.

Correct answer: C

Rationale: When measuring blood pressure, it's important to account for the possibility of an auscultatory gap, which occurs in about 5% of individuals, particularly those with hypertension due to a noncompliant arterial system. To detect an auscultatory gap, the cuff should be inflated 20 to 30 mm Hg beyond the point at which the palpated pulse disappears. This ensures an accurate measurement of blood pressure by overcoming the potential gap in sounds. Choice A is correct as it follows this guideline. Choices B and C are incorrect because inflating the cuff to 200 mm Hg or above the patient's pulse rate does not address the specific issue of an auscultatory gap. Choice D is incorrect as it focuses on the patient's previous readings rather than the current measurement technique needed to detect an auscultatory gap.

4. The nurse is preparing to perform a physical assessment. The correct action by the nurse is reflected by which statement?

• A. Performs the examination from both sides of the bed.
• B. Examines tender or painful areas last to help relieve the patient's anxiety.
• C. Follows a flexible examination sequence, considering the patient's age and condition.
• D. Organizes the assessment to ensure that the patient does not change positions too often.

Correct answer: D

Rationale: The nurse should organize the assessment to minimize the patient's need to change positions frequently, ensuring efficiency and comfort. It is essential to perform the examination from both sides of the bed to facilitate a comprehensive assessment. Examining tender or painful areas last can help reduce patient discomfort and anxiety. The examination sequence should be flexible, taking into account the patient's age, condition, and specific needs. This approach allows for a tailored and patient-centered assessment, optimizing the quality of care provided.

5. Which of these statements is true regarding the use of Standard Precautions in the healthcare setting?

• A. Standard Precautions apply to all body fluids, except sweat.
• B. Alcohol-based hand rub should be used if hands are not visibly dirty.
• C. Standard Precautions are intended for use with all patients, regardless of their risk or presumed infection status.
• D. Standard Precautions are to be used only when non-intact skin, excretions containing visible blood, or expected contact with mucous membranes are present.

Correct answer: C

Rationale: Standard Precautions are designed to reduce the risk for transmission of microorganisms from both recognized and unrecognized sources. They are intended for use with all patients, regardless of their risk or presumed infection status. Standard Precautions apply to all body fluids, secretions, and excretions except sweat - whether or not they contain visible blood, non-intact skin, or mucous membranes. Hands should be washed with soap and water if visibly soiled with blood or body fluids. Alcohol-based hand rubs can be used if hands are not visibly soiled. Choice A is incorrect because Standard Precautions apply to all body fluids, secretions, and excretions except sweat. Choice B is incorrect because alcohol-based hand rub should be used when hands are not visibly dirty. Choice D is incorrect because Standard Precautions are not limited to situations involving non-intact skin, excretions with visible blood, or expected mucous membrane contact.

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