Nursing Elites

1. To properly read a meniscus,

• A. hold the measuring device at eye level and read the bottom of the curve of the liquid level
• B. hold the measuring device at eye level and read the top of the curve of the liquid level where the liquid adheres to the walls of the container.
• C. hold the measuring device at table level and, looking down into the measuring device, read the bottom of the curve of the liquid level.
• D. hold the measuring device at table level and, looking down into the measuring device, read the top of the curve of the liquid level.

Correct answer: A

Rationale: To properly read a meniscus, it is essential to hold the measuring device at eye level to avoid parallax error. Reading the bottom of the curve of the liquid level is correct because the meniscus is the concave or convex curve at the liquid's surface. Choice B is incorrect because reading the top of the curve where the liquid adheres to the walls of the container can lead to inaccurate measurements. Choices C and D are incorrect as they suggest holding the device at table level, which can introduce parallax error and result in an incorrect reading.

2. What technique would the nurse use to accurately assess a rectal temperature in an adult?

• A. Use a lubricated blunt tip thermometer.
• B. Insert the thermometer 2 to 3 inches into the rectum.
• C. Leave the thermometer in place for up to 8 minutes if the patient is febrile.
• D. Wait 2 to 3 minutes if the patient has recently smoked a cigarette.

Correct answer: A

Rationale: To accurately assess a rectal temperature in an adult, a nurse should use a lubricated rectal thermometer with a short, blunt tip. The thermometer is inserted only 2 to 3 cm (1 inch) into the rectum and left in place for 2 minutes. Choice B is incorrect as inserting the thermometer 2 to 3 inches would be too deep and inaccurate. Choice C is incorrect as leaving the thermometer in place for up to 8 minutes is unnecessary and can cause discomfort. Choice D is incorrect as smoking a cigarette does not impact rectal temperatures.

3. In which of these patients would rectal temperatures be measured?

• A. Older adult
• B. Critically ill patient
• C. School-age child
• D. Patient receiving oxygen via nasal cannula

Correct answer: B

Rationale: Rectal temperature measurement is preferred in situations where other routes are impractical or when the most accurate measure is necessary, such as in critically ill patients. The rectal route may be chosen due to its reliability in such cases. For older adults, school-age children, and patients receiving oxygen via nasal cannula, rectal temperature measurement is not typically indicated. Other routes like oral, tympanic, or axillary measurements are more commonly used in these populations due to comfort, convenience, and non-invasive nature.

4. A patient with Parkinson's disease is experiencing difficulty swallowing. What potential problem associated with dysphagia has the greatest influence on the plan of care?

• A. Anorexia
• B. Aspiration
• C. Self-care deficit
• D. Inadequate intake

Correct answer: B

Rationale: When a person experiences dysphagia (difficulty swallowing), the greatest concern is aspiration. Aspiration occurs when food or fluids enter the trachea and lungs instead of going down the esophagus. This can lead to serious complications such as choking, airway obstruction, and aspiration pneumonia. Anorexia (Choice A) refers to a loss of appetite, which is not the primary concern with dysphagia. Self-care deficit (Choice C) and inadequate intake (Choice D) are important considerations but do not have as direct an impact on the immediate safety and health risks associated with aspiration in dysphagia.

5. While auscultating heart sounds, the nurse hears a murmur. Which of these instruments would be used to assess this murmur?

• A. Electrocardiogram
• B. Bell of the stethoscope
• C. Diaphragm of the stethoscope
• D. Palpation with the nurse's palm of the hand

Correct answer: B

Rationale: The correct instrument to assess a murmur while auscultating heart sounds is the bell of the stethoscope. An electrocardiogram is used to measure the heart's electrical activity, not to assess murmurs. Palpation with the nurse's palm of the hand is a method to assess pulses or textures, not heart murmurs. The diaphragm of the stethoscope is typically used for high-pitched sounds like breath, bowel, and normal heart sounds, whereas the bell is more suitable for soft, low-pitched sounds such as murmurs or extra heart sounds.

Similar Questions