Nursing Elites

1. Which of the following is an anthropometric measurement?

• A. Blood pressure
• B. Temperature
• C. Pulse Rate
• D. Weight

Correct answer: D

Rationale: Anthropometric measurements relate to the size, weight, and proportions of the human body. Weight is a key anthropometric measurement as it directly reflects body mass, making it the correct choice. Blood pressure, temperature, and pulse rate are physiological measurements that do not specifically pertain to body size or proportion, hence making them incorrect choices in the context of anthropometric measurements.

2. Your elderly patient has a temperature of 98.5 degrees. Is there anything else that a nurse should do, in addition to documenting this temperature?

• A. No, this temperature is within normal limits.
• B. No, this temperature is normally hyperthermic.
• C. Yes, this temperature is highly hyperthermic.
• D. Yes, this temperature is highly hypothermic.

Correct answer: A

Rationale: No, there is nothing else that a nurse should do. A temperature of 98.5 degrees for an elderly patient falls within normal limits. Other choices are incorrect because the temperature is not hyperthermic (abnormally high) or hypothermic (abnormally low), making choices B, C, and D inaccurate responses in this scenario.

3. To accurately assess a patient's respiration rate, which of the following methods would be BEST?

• A. Tell the patient, 'Please remain silent while I count your number of breaths.'
• B. Count respirations at the same time you are counting the pulse rate
• C. Count the pulse rate for one minute, then, while keeping your index fingers on the patient's radial artery, count the respirations for an additional minute.
• D. Count the patient's respiration rate, then take the patient's temperature, and then take the pulse rate.

Correct answer: B

Rationale: The most accurate method to assess a patient's respiration rate is to count the breaths simultaneously while counting the pulse rate. This approach ensures that the patient is unaware of the specific focus on their breathing, preventing any conscious alteration in breathing patterns. Choice A is incorrect because informing the patient may lead to altered breathing as the patient may consciously change their breathing pattern. Choice C involves counting the pulse rate first, which is not necessary for assessing respiration rate. Choice D is incorrect as it includes unnecessary steps such as taking the patient's temperature before counting respiration rate, which adds no value to accurately assessing the respiration rate.

4. What is the minimum amount of personal protective equipment for a nurse when working with a newborn immediately after a high-risk delivery in a client's room?

• A. Sterile gown, gloves
• B. Mask, gown, shoe covers
• C. Gloves
• D. Hat, mask, gloves, gown, shoe covers

Correct answer: C

Rationale: The correct answer is gloves. When attending a high-risk delivery and handling a newborn immediately after birth, the minimum personal protective equipment required for a nurse includes gloves. This is essential to protect the nurse from potential exposure to the mother's blood or body fluids that may be present on the newborn's skin. Choices A, B, and D include additional protective equipment that is not necessary for this specific scenario. Wearing gloves is crucial for infection control and to prevent the transmission of pathogens.

5. A client's intake and output are being calculated by a nurse. During the last shift, the client consumed � cup of gelatin, a skinless chicken breast, 1 cup of green beans, and 300 cc of water. The client also urinated 250 cc and had 2 bowel movements. What is this client's intake and output for this shift?

• A. 420 cc intake, 250 cc output
• B. 300 cc intake, 250 cc output
• C. 550 cc intake, 550 cc output
• D. 300 cc intake, 550 cc output

Correct answer: A

Rationale: The correct answer is 420 cc intake and 250 cc output for this shift. To calculate the intake, � cup of gelatin (approximately 120 cc) and 300 cc of water should be added together, resulting in 420 cc. Food intake like the chicken breast and green beans is not converted to cc's but may be documented for hospital protocol. Output includes urine (250 cc in this case) and other forms like vomit, diarrhea, or gastric suction. Bowel movements are not converted to cc's, but the nurse may need to document the number of stools passed. Choices B, C, and D are incorrect because they do not accurately reflect the intake and output calculations based on the information provided.

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