Nursing Elites

1. The nurse is preparing to assist in examining a Hispanic child who was brought to the clinic by the mother. During the assessment of the child, the nurse should take which action(s)?

• A. Admiring the child
• B. Taking the child’s temperature
• C. A, D
• D. Obtaining an interpreter if necessary

Correct answer: C

Rationale: In a multicultural healthcare setting, it's essential for the nurse to build rapport with the child and family. Admiring the child can help establish trust and comfort. Additionally, since the child's mother brought them to the clinic, it's crucial to ensure effective communication. Obtaining an interpreter, if necessary, is vital for clear and accurate information exchange. Taking the child's temperature, while important in a physical assessment, is not specifically highlighted in this scenario. Therefore, choices A and B alone are not sufficient, making the correct answer C, which includes both building rapport by admiring the child and ensuring clear communication by obtaining an interpreter if needed.

2. The nurse has been assigned to train the unlicensed nursing assistant about prioritizing care. Which client should the nurse instruct the unlicensed nursing assistant to see first?

• A. The client who needs both sequential compression devices removed
• B. The elderly woman who needs assistance ambulating to the bathroom
• C. The surgical client who needs help changing the gown after bathing
• D. The male client who needs the intravenous fluid discontinued

Correct answer: A

Rationale: The correct answer is A because removing sequential compression devices could increase the risk of thromboembolism, making it the priority. Choice B involves assisting with ambulation, which can be done after addressing the urgent need of the client in choice A. Choice C and D involve non-urgent tasks compared to the potential risks associated with not removing sequential compression devices promptly.

3. Before administering an MMR (measles, mumps, and rubella) vaccine to a 15-month-old, which question should the nurse ask the mother of the child?

• A. “Has your child had any sore throats?”
• B. “Has your child been eating properly?”
• C. “Is your child allergic to any antibiotics?”
• D. “Has your child been exposed to any infections?”

Correct answer: C

Rationale: The correct question for the nurse to ask the mother before administering the MMR vaccine to a 15-month-old is about the child's allergy to antibiotics. This is crucial because the MMR vaccine contains neomycin, an antibiotic, and being allergic to antibiotics like neomycin is a contraindication for the MMR vaccine. Asking about sore throats, eating habits, or exposure to infections is not directly relevant to the administration of the MMR vaccine.

4. Protecting the rights and privacy of the patient and their family is part of which of the following steps for determining and fulfilling the nursing care needs of the patient?

• A. Evaluation
• B. Planning
• C. Implementation
• D. Assessment

Correct answer: C

Rationale: The correct answer is C: Implementation. Implementation is the phase where the nursing care plan is put into action, which includes safeguarding the patient's and their family's rights and privacy. Evaluation (choice A) involves reviewing the effectiveness of the care plan, Planning (choice B) is the phase where the care plan is developed, and Assessment (choice D) is the initial step where data about the patient is collected.

5. In supply and equipment management, what is the FIRST step in the procurement process?

• A. Keep hand receipts up to date
• B. Establish requirements
• C. Requisition supplies and equipment through the proper channels
• D. Properly receive, inspect, and store required items

Correct answer: B

Rationale: In the procurement process, the FIRST step is to establish requirements. This step involves identifying and defining the needs for supplies and equipment before moving forward with the procurement process. Keeping hand receipts up to date (Choice A) is a task related to tracking and managing inventory but comes after the requirements have been established. Requisitioning supplies and equipment (Choice C) and receiving, inspecting, and storing items (Choice D) are subsequent steps in the procurement process that follow after the requirements have been determined.

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