Nursing Elites

1. When examining an older adult, which technique should the nurse use?

• A. Minimize touching the patient as much as possible.
• B. Attempt to perform the entire physical examination during one visit.
• C. Speak loudly and slowly due to potential hearing deficits in aging adults.
• D. Arrange the sequence of the examination to allow as few position changes as possible.

Correct answer: D

Rationale: When examining an older adult, it is crucial to arrange the sequence of the examination to minimize position changes. This helps prevent discomfort and fatigue for the older adult, who may have mobility issues. Option A is incorrect because physical touch is essential when examining older adults, as their other senses may be diminished. Option B is incorrect as it is better to break the examination into multiple visits to ensure thoroughness and comfort. Option C is incorrect because while some older adults may have hearing deficits, it is not appropriate to assume this for all individuals without proper assessment.

2. When caring for children with a different cultural perspective, what challenge may the nurse recognize?

• A. Children have spiritual needs that are influenced by their stages of development
• B. Children have spiritual needs that are direct reflections of what is occurring in their homes
• C. Religious beliefs rarely affect the parents' perceptions of the illness
• D. Parents are often the decision-makers, and they have no knowledge of their children's spiritual needs

Correct answer: A

Rationale: When caring for children with different cultural perspectives, nurses should acknowledge that children have spiritual needs that are influenced by their stages of development. This understanding is crucial as children, like adults, have varying spiritual needs based on their age and the religious environment within their family. Recognizing and addressing these spiritual needs is essential for providing holistic care. Choices B, C, and D are incorrect as they do not accurately reflect the influence of children's developmental stages on their spiritual needs and the importance of considering these needs in their care.

3. When measuring the vital signs of a 6-month-old infant, which action by the nurse is correct?

• A. Respirations are measured first, followed by pulse and temperature.
• B. Vital signs should be measured as frequently as in an adult.
• C. Procedures are explained to the parent, and the infant is encouraged to handle the equipment.
• D. The nurse should first measure the infant's vital signs before performing a physical examination.

Correct answer: A

Rationale: When assessing vital signs in a 6-month-old infant, the correct order is to measure respirations first, followed by pulse and temperature. This sequence is important to avoid potential alterations in respiratory and pulse rates caused by factors like crying or discomfort. Measuring the temperature first, especially rectally, may lead to an increase in respiratory and pulse rates, which can skew the results. It is crucial to follow this specific order to obtain accurate baseline values. Therefore, option A is the correct choice. Option B is incorrect as the frequency of measuring vital signs in infants differs based on individual needs rather than being consistently more frequent than in adults. Option C is not directly related to the correct sequence for measuring vital signs in infants. Option D is incorrect because the physical examination typically follows the assessment of vital signs in clinical practice.

4. A client is being assisted to lie in the Sims' position. In what position does the nurse arrange the client?

• A. The client lies on his side with the upper leg flexed
• B. The client lies on his back with his head lower than his feet
• C. The client lies on his abdomen with a pillow supporting his head
• D. The client is sitting up at a 90-degree angle

Correct answer: A

Rationale: The Sims' position is a side-lying position used for examinations or comfort. In the Sims' position, the client lies on their side with the upper leg flexed. The abdomen is slightly downward, and the lower arm is positioned behind the body. A pillow can be used to support the leg. Choice B is incorrect as it describes a position with the client lying on their back with the head lower than the feet. Choice C is incorrect as it describes a prone position, not the Sims' position. Choice D is incorrect as it describes a sitting position, not the Sims' position.

5. When a nurse's hand comes in contact with a client's blood after providing wound care, what is the next action the nurse should take?

• A. Use an alcohol-based hand sanitizer to disinfect the hands
• B. Wash hands with soap and water using appropriate technique
• C. Notify the appropriate personnel about the exposure to client's blood
• D. Sample some of the client's blood to determine the presence of diseases

Correct answer: B

Rationale: When a nurse's hand comes in contact with a client's blood, it is important to follow appropriate infection control measures. Using an alcohol-based hand sanitizer is not sufficient in this scenario as the blood is a visible contaminant. The best practice is to wash hands with soap and water using appropriate technique to ensure thorough cleansing and removal of any potential pathogens. Notifying the appropriate personnel about the exposure is important for documentation and further evaluation, but immediate hand hygiene is crucial. Sampling the client's blood for disease determination is not within the nurse's scope of practice and is unnecessary in this situation.

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