Nursing Elites

1. When checking for proper blood pressure cuff size, which guideline is correct?

• A. The standard cuff size is appropriate for all sizes.
• B. The length of the rubber bladder should equal 80% of the arm circumference.
• C. The width of the rubber bladder should equal 80% of the arm circumference.
• D. The width of the rubber bladder should equal 40% of the arm circumference.

Correct answer: D

Rationale: When selecting the correct blood pressure cuff size, it is essential to ensure that the width of the rubber bladder equals 40% of the circumference of the person's arm. This ensures proper fitting and accurate readings. The length of the bladder should actually equal 80% of the arm circumference, not 80% of the width, making choices B and C incorrect. Choice A stating that the standard cuff size is appropriate for all sizes is inaccurate, as using an incorrectly sized cuff can lead to inaccurate blood pressure readings.

2. During a general survey of a patient, which finding is considered normal?

• A. Body mass index (BMI) of 20.
• B. When standing, the patient's base is narrow.
• C. The patient appears older than their stated age.
• D. Arm span (fingertip to fingertip) is greater than the height.

Correct answer: A

Rationale: A body mass index (BMI) of 20 is considered normal as the range for a normal BMI is between 19-24. When standing, a patient's base should be wide for stability and proper weight distribution. An older appearance than the stated age may indicate a history of chronic illness or chronic alcoholism. In a general survey, the patient's arm span (fingertip to fingertip) should approximately equal the patient's height. An arm span greater than the height may suggest Marfan syndrome. Therefore, the correct choice is a normal BMI of 20, which falls within the healthy range. Choices B, C, and D all describe abnormal findings that may indicate underlying health conditions or syndromes.

3. To which of the following do the CDC Standard precautions recommendations apply?

• A. Patients with diagnosed infections only
• B. Blood or body fluids with visible blood only
• C. All body fluids including sweat
• D. All patients receiving care in hospitals

Correct answer: D

Rationale: The correct answer is 'All patients receiving care in hospitals.' Standard precautions apply to all patients in healthcare settings, regardless of their infection status. These recommendations include all body fluids except sweat, non-intact skin, and mucous membranes. Choice A is incorrect as standard precautions are not limited to patients with diagnosed infections. Choice B is incorrect as standard precautions extend beyond blood or body fluids with visible blood. Choice C is incorrect as sweat is an exception to the body fluids covered under standard precautions.

4. A 2-year-old child has been brought to the clinic for a well-child checkup. What is the best way for the nurse to begin the assessment?

• A. Ask the parent to place the child on the examining table.
• B. Have the parent remove all of the child's clothing before the examination.
• C. Allow the child to keep a security object such as a toy or blanket during the examination.
• D. Initially focus the interactions on the child, essentially ignoring the parent until the child's trust has been obtained.

Correct answer: C

Rationale: The best place to examine the toddler is on the parent's lap. Toddlers understand symbols; therefore, a security object is helpful. Initially, the focus is more on the parent, which allows the child to adjust gradually and to become familiar with you. A 2-year-old child does not like to take off his or her clothes. Therefore, ask the parent to undress one body part at a time.

5. During which part of the client interview would it be best for the nurse to ask, 'What's the weather forecast for today?'

• A. Introduction
• B. Body
• C. Closing
• D. Orientation

Correct answer: A

Rationale: Asking about the weather initiates the social or introductory phase of the interview, allowing the nurse to establish rapport with the client at the beginning. This question can help assess the client's mental status and set a friendly tone. In the body phase, the client responds to the nurse's inquiries, while during the closing phase, either the nurse or the client concludes the interview. Therefore, the best time to ask about the weather forecast is during the introduction phase to facilitate a positive start to the interaction.

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