Nursing Elites

1. The nurse is teaching a student nurse about the different types of thermometers. When teaching the student about the advantages of the tympanic membrane thermometer (TMT), which statement would the nurse include?

• A. "Measuring temperature using the TMT is cost-effective."?
• B. "The rapid measurement of the TMT is beneficial for uncooperative younger children."?
• C. "TMT is not recommended for measuring core body temperature in newborn infants."?
• D. "TMT is not the preferred method for measuring body temperature in patients with otitis media."?

Correct answer: B

Rationale: The correct answer is "The rapid measurement of the TMT is beneficial for uncooperative younger children." TMT is ideal for young children who may not cooperate for oral temperatures or fear rectal temperatures. However, using TMT for newborn infants is not recommended due to inconsistencies in results. Measuring temperature with TMT is not necessarily cost-effective. The most accurate method for measuring core temperature is through rectal temperatures. TMT may not be the preferred method for patients with otitis media due to potential inaccuracies caused by fluid behind the tympanic membrane.

2. What is the BEST blood collection location for a newborn?

• A. the AC
• B. the veins of the forehead
• C. the heel
• D. the fingertips

Correct answer: C

Rationale: When collecting blood from newborns, it is safest and most commonly done by collecting blood from the lateral or medial aspect of the baby's heel. This location is preferred due to the accessibility of the veins and the minimal discomfort caused to the newborn. Veins in the forehead are not commonly used for blood collection in newborns. The fingertips are not optimal for blood collection in newborns due to their small size and the potential for causing discomfort. The AC (antecubital) area, typically used in adults for blood collection, is not recommended for newborns due to the size of their veins and the potential risk of injury.

3. A client on the nursing unit is terminally ill but remains alert and oriented. Three days after admission, the nurse observes signs of depression. The client states, 'I'm tired of being sick. I wish I could end it all.' What is the most accurate and informative way to record this data in a nursing progress note?

• A. Client appears to be depressed, possibly suicidal
• B. Client reports being tired of being ill and wants to die
• C. Client does not want to live any longer and is tired of being ill
• D. Client states, 'I'm tired of being sick. I wish I could end it all.'

Correct answer: D

Rationale: Subjective data includes thoughts, beliefs, feelings, perceptions, and sensations that are apparent only to the person affected and cannot be measured, seen, or felt by the nurse. This information should be documented using the client's exact words in quotes. The other options indicate that the nurse has drawn the conclusion that the client no longer wishes to live. From the data provided, the cues do not support this assumption. A more complete assessment should be conducted to determine if the client is suicidal.

4. How many cc are there in 25 ounces?

• A. 250
• B. 500
• C. 750
• D. 1000

Correct answer: C

Rationale: To convert ounces to cc, we know that there are 30 cc in 1 ounce. Therefore, to find out how many cc are in 25 ounces, we multiply 30 cc/ounce by 25 ounces which equals 750 cc. This makes choice C, 750, the correct answer. Choices A, B, and D are incorrect as they do not correctly convert ounces to cc.

5. A patient works with a nurse to establish outcomes. The nurse believes that one outcome suggested by the patient is not in the patient's best interest. What is the nurse's best action?

• A. Remain silent.
• B. Educate the patient that the outcome is not realistic.
• C. Explore with the patient possible consequences of the outcome.
• D. Formulate an appropriate outcome without the patient's input.

Correct answer: C

Rationale: In this scenario, the nurse should collaborate with the patient rather than impose personal opinions. While the nurse should respect the patient's autonomy, they also have a duty to provide guidance. By exploring possible consequences of the suggested outcome with the patient, the nurse can facilitate a discussion that helps the patient make an informed decision. This approach respects the patient's input while ensuring their well-being. Remaining silent (Choice A) may not address the issue, educating the patient unilaterally (Choice B) may be perceived as dismissive, and formulating an outcome without patient input (Choice D) disregards the patient's autonomy and preferences.

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