Nursing Elites

1. Which of these actions illustrates the correct technique for a nurse when assessing oral temperature with a glass thermometer?

• A. Wait 30 minutes if the patient has ingested hot or iced liquids.
• B. Leave the thermometer in place for 3 to 4 minutes if the patient is afebrile.
• C. Shake the glass thermometer down to 35.5°C before taking the patient's temperature.
• D. Place the thermometer at the base of the tongue and ask the patient to close his or her lips.

Correct answer: B

Rationale: The correct technique for assessing oral temperature with a glass thermometer involves leaving the thermometer in place for 3 to 4 minutes if the patient is afebrile and up to 8 minutes if the patient is febrile. Waiting 30 minutes if the patient has ingested hot or iced liquids is incorrect; instead, the nurse should wait 15 minutes in such cases. Shaking the glass thermometer down to 35.5°C, not 37.5°C, is the correct procedure before taking the patient's temperature. Placing the thermometer at the base of the tongue, not the front, and asking the patient to close their lips is the proper way to position the thermometer. Therefore, the correct answer is to leave the thermometer in place for 3 to 4 minutes if the patient is afebrile and up to 8 minutes if the patient is febrile.

2. After receiving change-of-shift report, which patient should the nurse assess first?

• A. A patient with pneumonia who has crackles in the right lung base
• B. A patient with possible lung cancer who has just returned after bronchoscopy
• C. A patient with hemoptysis and a 16-mm induration with tuberculin skin testing
• D. A patient with chronic obstructive pulmonary disease (COPD) and pulmonary function testing (PFT) that indicates low forced vital capacity

Correct answer: B

Rationale: The correct answer is the patient with possible lung cancer who has just returned after bronchoscopy. After bronchoscopy, the patient may have decreased cough and gag reflexes, necessitating immediate assessment for airway patency to prevent potential complications. The other patients do not exhibit urgent clinical manifestations or have undergone recent procedures that require immediate attention. Therefore, they can be assessed after ensuring the safety and stability of the patient who has just returned after bronchoscopy.

3. Which term best describes changes such as retirement, grandparenting, and increased dependence on others?

• A. Moral
• B. Psychosocial
• C. Self-esteem
• D. Psychomotor

Correct answer: B

Rationale: The correct answer is 'Psychosocial.' Retirement, grandparenting, and increased dependence on others are examples of psychosocial changes because they involve social interactions, relationships, and psychological aspects. 'Moral' (Choice A) does not directly relate to the changes mentioned. 'Self-esteem' (Choice C) is more about self-perception and confidence, not the social changes mentioned. 'Psychomotor' (Choice D) refers to physical movements and skills, which are not the focus of the changes described in the question.

4. Which action is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)?

• A. Listen to a patient's lung sounds for wheezes or rhonchi.
• B. Label specimens obtained during percutaneous lung biopsy.
• C. Instruct a patient about how to use home spirometry testing.
• D. Measure induration at the site of a patient's intradermal skin test.

Correct answer: B

Rationale: Labeling specimens obtained during a percutaneous lung biopsy is a task that can be appropriately delegated to unlicensed assistive personnel (UAP) as it does not require nursing judgment. UAP can perform this task safely under the supervision of a nurse. Listening to a patient's lung sounds for wheezes or rhonchi, instructing a patient about how to use home spirometry testing, and measuring induration at the site of a patient's intradermal skin test all require nursing judgment and interpretation of findings. These tasks should be performed by licensed nursing personnel to ensure accurate assessment and appropriate intervention.

5. Your patient had a stroke, or CVA, five years ago. The resident still has right-sided weakness. You are ready to transfer the resident from the bed to the wheelchair. The wheelchair should be positioned at the _____________.

• A. head of the bed on the patient's right side
• B. head of the bed on the patient's left side
• C. bottom of the bed on the patient's right side
• D. bottom of the bed on the patient's left side

Correct answer: B

Rationale: The wheelchair should be positioned at the head of the bed on the resident's left side. This positioning allows the resident to use their stronger left side to assist with the transfer, compensating for the right-sided weakness. Placing the wheelchair at the head of the bed on the patient's right side (Choice A) would not utilize the stronger left side, which is crucial for the transfer. Similarly, positioning the wheelchair at the bottom of the bed on either side (Choices C and D) would not facilitate optimal assistance from the resident's stronger side during the transfer process.

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