Nursing Elites

1. The student observes a patient with no breathing problems. Which action by the student indicates a need to review respiratory assessment skills?

• A. The student starts at the apices of the lungs and moves to the bases.
• B. The student compares breath sounds from side to side, avoiding bony areas.
• C. The student places the stethoscope over the posterior chest and listens during expiration.
• D. The student instructs the patient to breathe slowly and a little more deeply than normal through the mouth.

Correct answer: C

Rationale: The correct answer is C. Listening only during inspiration instead of both inspiration and expiration indicates a need for a review of respiratory assessment skills. During chest auscultation, it is essential to listen to at least one cycle of inspiration and expiration at each placement of the stethoscope. Instructing the patient to breathe slowly and a little deeper than normal through the mouth is a correct practice during auscultation. The correct sequence for lung auscultation is from the apices to the bases, comparing breath sounds bilaterally, avoiding bony areas. It is crucial to place the stethoscope over lung tissue rather than bony prominences to accurately assess lung sounds.

2. When preparing to perform a physical examination on an infant, what should the nurse do?

• A. Have the parent remove all clothing except the diaper.
• B. Instruct the parent not to feed the infant immediately before the examination.
• C. Allow the infant to suck on a pacifier during abdominal auscultation.
• D. Ensure the parent is present during the examination.

Correct answer: A

Rationale: For performing a physical examination on an infant, it is important to have the parent remove all clothing except the diaper to allow for a thorough examination while ensuring the infant remains comfortable. It is recommended not to feed the infant immediately before the examination but rather 1 to 2 hours after feeding when the baby is neither too drowsy nor too hungry. While a pacifier may be used during invasive assessments or if the infant is crying, it is not typically necessary during abdominal auscultation. Having the parent present during the examination is important for the infant's security and for the parent to understand the process; however, the clothing should still be removed except for the diaper to facilitate a comprehensive assessment.

3. A client is being seen for disrupted sleep patterns. The nurse encourages the client to verbalize feelings about sleep and inability to maintain adequate sleep habits. What is the rationale for this action?

• A. The client most likely has a mental illness that should be treated before addressing sleep issues
• B. The client may have unrecognized anxiety or fear that could be contributing to poor sleep habits
• C. The client may become tired once they start talking
• D. None of the above

Correct answer: B

Rationale: Clients experiencing disrupted sleep patterns may have underlying anxiety or fear contributing to their poor sleep habits. Encouraging clients to verbalize their feelings about sleep allows them to address any negative emotions that may be impacting their ability to sleep well. By working through these issues, clients may experience increased peace and relaxation, which can help promote better sleep. Option A is incorrect because assuming a mental illness without evidence can lead to mismanagement of the client's care. Option C is incorrect as it does not address the underlying emotional factors affecting the client's sleep patterns. Option D is incorrect as there is a specific rationale for encouraging the client to verbalize their feelings about sleep.

4. Which vacutainer tubes should be used when a requisition calls for blood to be drawn for an H&H and glucose test?

• A. One light blue, one red
• B. Two lavenders
• C. One lavender, one grey
• D. One green, one red

Correct answer: D

Rationale: The correct answer is 'One green, one red.' An H&H test involves hemoglobin and hematocrit, which are components of a complete blood count and are typically drawn in a lavender tube. On the other hand, blood for glucose testing is collected in grey tubes. Therefore, when drawing blood for both an H&H and glucose test, one green tube for glucose and one red tube for H&H should be used. The other choices are incorrect because light blue tubes are used for coagulation studies, lavender tubes are for complete blood counts, and green tubes are for chemistry tests like glucose, while grey tubes are specifically for glucose testing.

5. Which of the following is the correct sequence for removing personal protective equipment?

• A. Remove gown, gloves, shoe covers, mask
• B. Remove mask, gloves, gown, shoe covers
• C. Remove gloves, gown, mask, shoe covers
• D. Remove shoe covers, mask, gloves, gown

Correct answer: C

Rationale: The correct sequence for removing personal protective equipment is crucial to prevent contamination. When exiting a surgical or aseptic situation, the proper sequence is to first remove gloves, followed by the gown, mask, and finally shoe covers. This order ensures that potentially contaminated items are removed first, minimizing the risk of exposure. Choice A, 'Remove gown, gloves, shoe covers, mask,' is incorrect as gloves should be removed before the gown. Choice B, 'Remove mask, gloves, gown, shoe covers,' is incorrect as gloves should be removed first. Choice D, 'Remove shoe covers, mask, gloves, gown,' is incorrect as gloves should be the first item removed to prevent contamination.

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