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. Your patient has finished a 12-ounce can of iced tea and 8 ounces of fresh orange juice. What will you record on the Intake and Output form for this patient's intake?

• A. 20 cc
• B. 20 cm
• C. 600 cc
• D. 600 cm

Correct answer: C

Rationale: You will record 600 cc of fluid intake. There are 600 cc in 20 ounces (12 ounces of iced tea + 8 ounces of orange juice) of fluid intake. Choice A and B are incorrect as they do not reflect the correct conversion of fluid intake from ounces to cubic centimeters. Choice D is incorrect as it provides the measurement in cubic centimeters but does not account for the total fluid intake accurately.

3. A healthcare professional is employed at a district health department and must spend several hours each day sitting at a desk. Which principle of ergonomics will most likely help them to reduce the risk of injury or pain in this situation?

• A. Adjust the chair height to keep the legs bent at the hips at a 90-degree angle
• B. Maintain the position of the computer monitor just below eye level
• C. Stand up and take a walk or stretch every 4 hours
• D. Rest wrists on the edge of the desk while typing

Correct answer: A

Rationale: When sitting for prolonged periods, it is important to adjust the height of the chair so that the legs are bent at the hips at a 90-degree angle. This position helps to reduce pressure on the back, legs, and feet, promoting better posture and reducing muscle fatigue. Standing up and moving around at least once every hour is crucial to support circulation and prevent stiffness. Maintaining the position of the computer monitor just below eye level helps reduce strain on the neck and eyes. Resting wrists on the edge of the desk while typing can lead to wrist strain and discomfort, so it is not an ergonomic recommendation for prolonged desk work.

4. What term is used to refer to generalized wasting of body tissues and malnutrition?

• A. Entropion
• B. Confabulation
• C. Induration
• D. Cachexia

Correct answer: D

Rationale: Cachexia is the correct term used to describe the generalized wasting of body tissues, ill health, and malnutrition associated with some chronic diseases. It involves a loss of fat tissue to protect the bones and joints. Clients with cachexia are at risk of pressure ulcers and other complications due to malnutrition and poor health. Entropion refers to an eyelid condition, confabulation is a memory disturbance, and induration is the abnormal hardening of a part of the body.

5. A client is preparing to administer an enema to a 64-year-old client. Which of the following actions of the nurse is most appropriate?

• A. Assist the client to lie in the semi-Fowler position
• B. Apply lubricating jelly to the tip of the catheter before insertion
• C. Instill a total of 30cc of fluid into the client's rectum
• D. Ask the client to hold the solution in for 30 seconds

Correct answer: B

Rationale: When administering an enema to a client, the nurse should place the client in the Sims' position for easy access. The correct action is to apply lubricating jelly to the tip of the catheter before insertion to facilitate a smoother procedure. It is essential to instill a maximum of 750 to 1000 cc of fluid for an adult client, not just 30cc. Following administration, the nurse should ask the client to hold the solution for at least 5 minutes to allow for the desired effect of the enema. Therefore, choice B is the most appropriate action, as choices A, C, and D are incorrect due to inaccuracies in positioning, enema volume, and retention time.

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