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. What is the best outcome for a patient with the nursing diagnosis: Impaired social interaction related to sociocultural dissonance, as evidenced by stating, "Although I'd like to, I don't join in because I don't speak the language very well?"? The patient will:

• A. demonstrate improved social skills
• B. express a desire to interact with others
• C. become more independent in decision-making
• D. select and participate in one group activity per day

Correct answer: D

Rationale: The correct outcome for the patient with impaired social interaction related to sociocultural dissonance is to select and participate in one group activity per day. This outcome focuses on increasing social involvement, which aligns with addressing the nursing diagnosis. The patient has already expressed a desire to interact with others, so the goal is to facilitate actual participation in social activities. Becoming more independent in decision-making and demonstrating improved social skills are not directly related to the specific nursing diagnosis provided. Additionally, the outcomes must be measurable, making choices A and C less appropriate as they lack specificity and measurability.

3. A healthcare professional is preparing to administer an enteral feeding through a gastrostomy tube. Before administering the feeding, the healthcare professional aspirates some stomach contents and checks the pH. The result is 3.9. What is the next action of the healthcare professional?

• A. Administer the feeding as ordered
• B. Pull the feeding tube out approximately 3 cm
• C. Flush the feeding tube with 60 cc of water
• D. Contact the physician

Correct answer: A

Rationale: When the pH of the aspirated stomach contents is 4 or less, it indicates that the gastrostomy tube is in the stomach, confirming correct placement. A pH of 3.9 falls within this range, so the healthcare professional can proceed with administering the enteral feeding. There is no need to adjust the tube placement, flush with water, or contact the physician in this situation as the tube is appropriately positioned for feeding.

4. The nurse should wash from the ________________________ when washing a patient's eye area.

• A. outer canthus to the inner canthus
• B. inner canthus to the outer canthus
• C. internal nares to the external nares
• D. external nares to the internal nares

Correct answer: B

Rationale: When washing a patient's eye area, it is important to start from the inner canthus (closest to the nose) and move towards the outer canthus. This direction prevents any contaminants or debris from the outer area of the eye from moving towards the inner, more sensitive area. Choices C and D are incorrect as they pertain to the nasal passages (nares), which are not relevant when washing the eye area.

5. After taking the vital signs for your patient and finding them to be normal, what should you do next?

• A. Report the vital signs to the doctor
• B. Write the vital signs on a scrap paper
• C. Call the family members
• D. Document them on the graphic VS form

Correct answer: D

Rationale: After assessing and finding that the vital signs are normal for the patient, the appropriate action would be to document them on the graphic VS form. This form is used to track and record vital sign measurements accurately and consistently. Reporting the normal vital signs to the doctor is not necessary unless there are concerning trends or deviations. Writing the vital signs on a scrap piece of paper is not recommended as it may not be an official or reliable record. Calling the family members is unrelated to the process of documenting and tracking vital signs for the patient.

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