Nursing Elites

1. Your patient has finished a 12-ounce can of iced tea and 8 ounces of fresh orange juice. What will you record on the Intake and Output form for this patient's intake?

• A. 20 cc
• B. 20 cm
• C. 600 cc
• D. 600 cm

Correct answer: C

Rationale: You will record 600 cc of fluid intake. There are 600 cc in 20 ounces (12 ounces of iced tea + 8 ounces of orange juice) of fluid intake. Choice A and B are incorrect as they do not reflect the correct conversion of fluid intake from ounces to cubic centimeters. Choice D is incorrect as it provides the measurement in cubic centimeters but does not account for the total fluid intake accurately.

2. In which of the following ways can a healthcare provider promote the sense of taste for an older adult?

• A. Mixing foods together on the dinner tray
• B. Avoiding cologne, air fresheners, or room deodorizers
• C. Encouraging the client to chew food thoroughly
• D. Discouraging the use of salt or seasonings with prepared food

Correct answer: C

Rationale: As individuals age, their sense of taste may diminish, impacting the enjoyment of eating. One effective way for a healthcare provider to promote the sense of taste for an older adult is by encouraging them to chew food thoroughly. Thorough chewing increases the contact of food with the taste buds, enhancing the chances of experiencing the flavors. Mixing foods together on the dinner tray may not necessarily enhance taste perception. Avoiding strong scents like cologne, air fresheners, or room deodorizers is more related to olfactory senses rather than taste. Discouraging the use of salt or seasonings can further diminish the taste experience for older adults who may already have reduced taste sensitivity.

3. The nurse is teaching a student nurse about the different types of thermometers. When teaching the student about the advantages of the tympanic membrane thermometer (TMT), which statement would the nurse include?

• A. "Measuring temperature using the TMT is cost-effective."?
• B. "The rapid measurement of the TMT is beneficial for uncooperative younger children."?
• C. "TMT is not recommended for measuring core body temperature in newborn infants."?
• D. "TMT is not the preferred method for measuring body temperature in patients with otitis media."?

Correct answer: B

Rationale: The correct answer is "The rapid measurement of the TMT is beneficial for uncooperative younger children." TMT is ideal for young children who may not cooperate for oral temperatures or fear rectal temperatures. However, using TMT for newborn infants is not recommended due to inconsistencies in results. Measuring temperature with TMT is not necessarily cost-effective. The most accurate method for measuring core temperature is through rectal temperatures. TMT may not be the preferred method for patients with otitis media due to potential inaccuracies caused by fluid behind the tympanic membrane.

4. While assisting a client from bed to chair, the nurse observes that the client looks pale and is beginning to perspire heavily. The nurse would then do which of the following activities as a reassessment?

• A. Help client into the chair more quickly
• B. Document client's vital signs taken just prior to moving the client
• C. Help client back to bed immediately
• D. Observe client's skin color and take another set of vital signs

Correct answer: D

Rationale: In this scenario, the nurse has observed concerning signs in the client during the transfer process. The appropriate action for reassessment would be to observe the client's skin color and take another set of vital signs. This will provide essential data to evaluate the client's condition more accurately. Options A, B, and C are interventions that do not address the need for reassessment. Moving the client more quickly, documenting previous vital signs, or returning the client to bed do not directly address the need to reassess the client's current condition.

5. During the examination, it is often appropriate to offer some brief teaching about the patient's body or the examiner's findings. Which one of these statements by the nurse is most appropriate?

• A. "Your atrial dysrhythmias are under control."?
• B. "You have pitting edema and mild varicosities."?
• C. "Your pulse is 80 beats per minute, which is within the normal range."?
• D. "I'm using my stethoscope to listen for any crackles, wheezes, or rubs in your lungs."?

Correct answer: C

Rationale: During an examination, providing brief educational information to the patient can enhance rapport, as long as the patient can comprehend the terminology. The most appropriate statement from the nurse is "Your pulse is 80 beats per minute, which is within the normal range." This statement conveys a vital sign in a way that is likely understandable to the patient. Choices A, B, and D use terminology that may be unfamiliar or confusing to the patient. Option A mentions 'atrial dysrhythmias,' which might not be clear to the patient. Option B involves terms like 'pitting edema' and 'varicosities,' which could be unfamiliar to the patient. Option D references 'crackles,' 'wheezes,' and 'rubs,' which might not be easily understood by the patient.

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