Nursing Elites

1. How does the procedure for taking a pulse rate on an infant differ from an adult?

• A. Pulse rates are taken on infants using a different method.
• B. The apical pulse method is used on infants.
• C. Pulse rates on infants are taken with a sphygmomanometer.
• D. Pulse rates on infants are taken apically in the third intercostal space.

Correct answer: B

Rationale: The correct answer is B: The apical pulse method is used on infants. This method involves placing a stethoscope in the fifth intercostal space, mid-clavicular line, and counting the beats for a full minute. It is a preferred method for infants due to their small size and the difficulty in palpating peripheral pulses accurately. Choices A, C, and D are incorrect. Choice A is incorrect as pulse rates are indeed taken on infants, albeit using a different method. Choice C is incorrect as a sphygmomanometer is typically used for measuring blood pressure, not pulse rates. Choice D is incorrect as pulse rates on infants are usually taken apically in the fifth intercostal space, not the third.

2. For the nursing diagnostic statement, Self-care deficit: feeding related to bilateral fractured wrists in casts, what is the major related factor or risk factor identified by the nurse?

• A. Discomfort
• B. Deficit
• C. Feeding
• D. Fractured wrists

Correct answer: D

Rationale: The correct answer is 'Fractured wrists.' In a nursing diagnostic statement, the related factor or risk factor is the underlying cause of the identified problem. In this case, the major factor affecting the self-care deficit in feeding is the bilateral fractured wrists in casts. The fractured wrists directly impact the client's ability to feed themselves, making it the primary related factor. Choices A, B, and C are incorrect as discomfort, deficit, and feeding are not the primary cause of the feeding problem in this scenario; rather, it is the physical limitation caused by the fractured wrists that is the focus of the nursing intervention.

3. During the evaluation of the quality of home care for a client with Alzheimer's disease, the priority for the nurse is to reinforce which statement by a family member?

• A. "At least two (2) full meals a day are eaten."?
• B. "We go to a group discussion every week at our community center."?
• C. "We have safety bars installed in the bathroom and have 24-hour alarms on the doors."?
• D. "The medication is not a problem to have taken three (3) times a day."?

Correct answer: C

Rationale: The correct answer is, '"We have safety bars installed in the bathroom and have 24-hour alarms on the doors."?' Ensuring the safety of a client with Alzheimer's disease is crucial in home care. Installing safety features like bars in the bathroom and alarms on doors help prevent accidents and injuries. This contributes to creating a safe environment that promotes independence and autonomy for the client. Choices A, B, and D are incorrect because while they are important aspects of care, ensuring safety in the home environment takes precedence in caring for a client with Alzheimer's disease.

4. A 51-year-old woman had an incisional cholecystectomy 6 hours ago. The nurse will place the highest priority on assisting the patient to

• A. choose low-fat foods from the menu
• B. perform leg exercises hourly while awake
• C. ambulate the evening of the operative day
• D. turn, cough, and deep breathe every 2 hours

Correct answer: D

Rationale: Postoperative nursing care after a cholecystectomy focuses on preventing respiratory complications due to the surgical incision being high in the abdomen, which impairs coughing and deep breathing. Turning, coughing, and deep breathing every 2 hours help prevent respiratory complications, such as pneumonia. While choices A, B, and C are also important aspects of postoperative care, they are not as high a priority as ensuring proper ventilation and respiratory function in the immediate postoperative period.

5. Which acronym would BEST describe the procedure for assessing a patient that appears unconscious?

• A. WBC
• B. QRS
• C. XYZ
• D. ABC

Correct answer: D

Rationale: The correct answer is D, 'ABC.' The ABC method stands for Airway, Breathing, Circulation. When encountering an unconscious patient, it is crucial to first ensure their Airway is clear by performing the 'head tilt, chin lift' maneuver. Next, assess Breathing by observing for chest rise and fall, listening for breath sounds, and feeling for airflow. Finally, check for Circulation by assessing for a pulse. Choices A, B, and C ('WBC,' 'QRS,' 'XYZ') are incorrect as they do not represent the standard approach to assessing an unconscious patient.

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