Nursing Elites

1. You have measured the urinary output of your resident at the end of your 8-hour shift. The output is 25 ounces. What should you do next?

• A. Convert the number of ounces into cc.
• B. Convert the number of ounces into cm.
• C. Immediately report this poor output to the nurse.
• D. Know that 25 ounces of urine is too much in 8 hours.

Correct answer: A

Rationale: You should convert the number of ounces into cc because cc is the unit of measurement used to record intake and output accurately. This urinary output falls within normal limits, so there is no need to report it immediately to the nurse. It is essential to report urinary outputs of less than 30 cc per hour to detect potential issues early. Converting ounces into centimeters (cm) is not appropriate in this context as cm is a unit of length, not volume. Knowing that 25 ounces of urine is too much in 8 hours is inaccurate as it depends on various factors like fluid intake and individual differences.

2. Where is the pulse point located on the top of the foot?

• A. the dorsalis pedis
• B. This is the pulse point checked in patients with peripheral vascular problems.
• C. This pulse point may be absent in some patients due to a congenital anomaly.
• D. All of the above.

Correct answer: D

Rationale: The pulse point located on the top of the foot is known as the dorsalis pedis pulse point. It is situated on the arch of the foot, slightly lateral to the midline. This pulse point is commonly examined in patients with peripheral vascular problems to assess blood flow adequacy. Additionally, some individuals may not have this pulse point due to a congenital anomaly. Therefore, all the given statements are correct in relation to the dorsalis pedis pulse point, making 'All of the above' the correct answer. Choices A, B, and C are all individually valid characteristics of the dorsalis pedis pulse point, hence selecting 'All of the above' as the correct answer is appropriate.

3. As a valued member of the team on your nursing care unit, you are trying to determine whether the team is doing well. Which of the following is a sign that your team is successful?

• A. Conflict occurs but is seen as an opportunity for team growth and development.
• B. No negative feelings are expressed, leading to everyone being happy and satisfied.
• C. Mistakes are not tolerated and result in disciplinary action.
• D. People avoid taking risks and stick to the status quo.

Correct answer: A

Rationale: One of the key indicators of a successful team is the ability to handle conflict positively. Conflict, when managed well, can lead to team growth and development. Choice B is incorrect because suppressing negative feelings does not indicate team success; open communication is crucial. Choice C is incorrect as successful teams view mistakes as learning opportunities rather than resorting to disciplinary action. Choice D is incorrect because successful teams are often innovative and willing to take risks rather than maintaining the status quo.

4. 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.

5. The nurse is taking an initial blood pressure reading on a 72-year-old patient with documented hypertension. How should the nurse proceed?

• A. Cuff should be placed on the patient's arm and inflated 30 mm Hg above the point at which the palpated pulse disappears.
• B. Cuff should be inflated to 200 mm Hg in an attempt to obtain the most accurate systolic reading.
• C. Cuff should be inflated 30 mm Hg above the patient's pulse rate.
• D. After confirming the patient's previous blood pressure readings, the cuff should be inflated 30 mm Hg above the highest systolic reading recorded.

Correct answer: C

Rationale: When measuring blood pressure, it's important to account for the possibility of an auscultatory gap, which occurs in about 5% of individuals, particularly those with hypertension due to a noncompliant arterial system. To detect an auscultatory gap, the cuff should be inflated 20 to 30 mm Hg beyond the point at which the palpated pulse disappears. This ensures an accurate measurement of blood pressure by overcoming the potential gap in sounds. Choice A is correct as it follows this guideline. Choices B and C are incorrect because inflating the cuff to 200 mm Hg or above the patient's pulse rate does not address the specific issue of an auscultatory gap. Choice D is incorrect as it focuses on the patient's previous readings rather than the current measurement technique needed to detect an auscultatory gap.

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