Nursing Elites

1. While measuring a client’s vital signs, the nurse notices an irregularity in the heart rate. Which nursing action is appropriate?

• A. Count the apical pulse rate for 1 full minute, and describe the rhythm in the chart
• B. Measure the blood pressure
• C. Perform an ECG
• D. Recheck the heart rate after 5 minutes

Correct answer: A

Rationale: The appropriate nursing action when an irregularity in the heart rate is observed is to count the apical pulse rate for a full minute and describe the rhythm in the chart. This approach helps in obtaining an accurate assessment of the irregularities present. Measuring the blood pressure (Choice B) is important but not the immediate priority when an irregular heart rate is noted. Performing an ECG (Choice C) may be necessary but is a more advanced intervention that should follow the initial assessment. Rechecking the heart rate after 5 minutes (Choice D) may delay potential interventions for addressing the irregularity, making it less appropriate than the immediate assessment and documentation of the pulse rhythm.

2. A nurse is caring for a client who has tuberculosis. Which of the following precautions should the nurse plan to implement when working with the client?

• A. Airborne
• B. Droplet
• C. Protective
• D. Contact

Correct answer: A

Rationale: Tuberculosis is an infectious disease that requires airborne precautions to prevent the transmission of infectious droplets. Airborne precautions involve wearing a mask, such as an N95 respirator, to protect against inhaling infectious particles. Droplet precautions are for diseases spread through respiratory droplets larger than those in airborne transmission, such as influenza. Protective precautions are not specific to respiratory infections and are more general measures to protect patients from harm. Contact precautions are used for diseases spread by direct or indirect contact, such as MRSA or C. diff infections, not for tuberculosis.

3. During the physical assessment of a client, which technique should a nurse use when performing a Romberg's test?

• A. Touch the client's face with a cotton ball
• B. Apply a vibrating tuning fork to the client's forehead
• C. Have the client stand with arms at her sides and feet together
• D. Perform direct percussion over the area of the kidneys

Correct answer: C

Rationale: During a Romberg's test, the nurse assesses the client's balance. Having the client stand with arms at her sides and feet together is the correct technique. This position helps the nurse observe for swaying or loss of balance, indicating alterations in balance. Choices A and B are incorrect as they are not part of Romberg's test and do not assess balance. Choice D is also incorrect as direct percussion over the kidneys is not associated with a Romberg's test.

4. A client with lower extremity weakness is being taught a four-point crutch gait by a nurse. Which of the following instructions should the nurse include in the teaching?

• A. Bear weight on both legs.
• B. Move the crutches and the weak leg in unison.
• C. Advance the crutches and the strong leg simultaneously.
• D. Move the crutches forward, then move one leg at a time.

Correct answer: D

Rationale: The correct technique for a four-point crutch gait involves moving the crutches forward, then moving one leg at a time. This method provides stability and support by alternating movement between the crutches and legs. Choice A is incorrect because bearing weight on both legs simultaneously is not the correct method for a four-point gait. Choice B is incorrect as moving the crutches and weak leg together does not provide the required stability. Choice C is incorrect as advancing the crutches and strong leg together does not promote the alternating movement needed for a four-point gait.

5. The client is being instructed on how to collect a clean catch urine specimen. Which sequence is appropriate for teaching?

• A. Void a little, clean the meatus, then collect specimen
• B. Clean the meatus, begin voiding, then catch urine stream
• C. Clean the meatus, then urinate into container
• D. Void continuously and catch some of the urine

Correct answer: B

Rationale: The correct sequence for obtaining a clean catch urine specimen involves first cleaning the meatus to prevent contamination, then initiating voiding to catch the midstream urine. This method ensures that the sample is as uncontaminated as possible, making choice B the correct sequence. Option A is incorrect as cleaning the meatus should be done before voiding. Option C is incorrect as it does not involve catching a midstream urine sample. Option D is incorrect as it suggests catching urine throughout the entire voiding process, which may lead to contamination.

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