Nursing Elites

1. You have been assigned to take an apical pulse for one of the patients on the nursing unit. How will you do this?

• A. You will place the stethoscope over the heart and listen for any irregular beats.
• B. You will place the stethoscope over the heart and count the beats per minute.
• C. You will place your fingertip over the patient's wrist and feel for any irregular beats.
• D. You will place your fingertip over the patient's wrist and count the beats per minute.

Correct answer: B

Rationale: To take an apical pulse accurately, you should place the stethoscope over the heart and count the number of beats per minute. This method provides a precise assessment of the heart rate. While listening for irregular beats is essential for assessing the heart's rhythm, the primary objective of taking an apical pulse is to determine the heart rate. Choices C and D are incorrect because the apical pulse is not taken at the wrist; instead, it is obtained by auscultating at the apex of the heart, usually at the point where the fifth intercostal space meets the midclavicular line.

2. A nurse is preparing to irrigate a client's indwelling catheter through a closed, intermittent system. Which of the following steps must the nurse take as part of this process?

• A. Use sterile solution at room temperature
• B. Position the client in a comfortable position
• C. Clamp the catheter at the level above the injection port
• D. Inject sterile solution through the injection port into the catheter

Correct answer: D

Rationale: When performing closed intermittent system catheter irrigation, the nurse should use sterile solution at room temperature with sterile technique. It is important to position the client comfortably for easy access to the catheter site and to assess the abdomen during the procedure. Clamping the catheter should be done below the level of the injection port, not above. The correct step is to inject sterile solution through the injection port into the catheter, allowing the fluid to travel up the catheter to irrigate the tubing and the bladder.

3. The nurse is preparing to examine a 6-year-old child. Which action is most appropriate?

• A. The child is asked to undress from the waist up.
• B. The head is examined before the thorax, abdomen, and genitalia.
• C. The nurse should keep in mind that a child at this age will have a sense of modesty.
• D. Talking about the equipment being used is avoided to prevent increasing the child's anxiety.

Correct answer: C

Rationale: When examining a 6-year-old child, it is important to consider their sense of modesty. The child should undress themselves, leaving underpants on and using a gown or drape to maintain privacy. Additionally, a school-age child like a 6-year-old is curious about how equipment works, so it is beneficial to explain the purpose and function of the tools being used. The examination sequence should typically progress from the child's head to the toes to ensure a thorough assessment. Therefore, choices A, B, and D are incorrect as they do not align with the appropriate approach to examining a 6-year-old child.

4. Which of the following safety precautions should the nurse discuss when working with an immunocompromised client?

• A. Avoid canned foods and increase consumption of fresh fruits and vegetables
• B. Hand-wash utensils after use and allow them to air dry
• C. Only drink tap water that has been filtered or boiled before consumption
• D. Never eat meals prepared in restaurants

Correct answer: C

Rationale: The correct answer is to only drink tap water that has been filtered or boiled before consumption. Immunocompromised clients are susceptible to infections, so it is essential to take precautions to prevent exposure to harmful pathogens. Drinking tap water that has been filtered or boiled helps eliminate potential pathogens that could be harmful to the client's health. Choices A, B, and D do not directly address the issue of avoiding potential pathogens that could compromise the health of an immunocompromised client. Thus, they are incorrect. Hand-washing utensils, avoiding canned foods, and increasing fruit and vegetable consumption are good general hygiene practices but may not specifically address the needs of an immunocompromised client.

5. The Sinoatrial Node (SA) is located within which of the following heart structures?

• A. Mitral Valve
• B. Right Ventricle
• C. Right Atrium
• D. Left Atrium

Correct answer: C

Rationale: The Sinoatrial (SA) Node, often called the heart's natural pacemaker, is situated within the upper wall of the Right Atrium. It initiates the electrical impulses that regulate the heartbeat. Choices A, B, and D are incorrect because the SA node is not located in the Mitral Valve, Right Ventricle, or Left Atrium. It is specifically positioned in the Right Atrium to coordinate the heart's rhythm and timing.

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