Nursing Elites

1. A 1-month-old infant has a head measurement of 34 cm and a chest circumference of 32 cm. Based on the interpretation of these findings, what action would the nurse take?

• A. Refer the infant to a physician for further evaluation.
• B. Consider these findings normal for a 1-month-old infant.
• C. Expect the chest circumference to be greater than the head circumference.
• D. Ask the parent to return in 2 weeks to re-evaluate the head and chest circumferences.

Correct answer: B

Rationale: In infants, a normal head measurement is approximately 32 to 38 cm, and it is usually around 2 cm larger than the chest circumference. These measurements vary with age; between 6 months and 2 years, both measurements are approximately the same, and after age 2 years, the chest circumference becomes greater than the head circumference. Given that the 1-month-old infant's head measurement is within the typical range and slightly larger than the chest circumference, the nurse should consider these findings normal. There is no indication to refer the infant for further evaluation or to have the parent return for re-evaluation in 2 weeks, as these measurements fall within the expected parameters for a 1-month-old infant.

2. Your patient ate an 8-ounce cup of Italian ice. How much will you record on the patient's Intake and Output form in terms of this patient's fluid intake?

• A. 240 cc
• B. 120 cc
• C. 8 cc
• D. 0 cc because Italian ice is not a fluid

Correct answer: A

Rationale: The correct answer is 240 cc. Italian ice is considered a fluid, so you would record the intake of 240 cc. Choice B (120 cc) and Choice C (8 cc) are incorrect as they do not reflect the correct amount of fluid intake from an 8-ounce cup of Italian ice. Choice D (0 cc) is incorrect because Italian ice does count as a fluid intake and should be recorded as such.

3. The hospital has sounded the call for a disaster drill on the evening shift. Which of these clients would the nurse prioritize first on the list to be discharged in order to make a room available for a new admission?

• A. A middle-aged client with a history of being ventilator dependent for over seven (7) years and admitted with bacterial pneumonia five days ago.
• B. A young adult with diabetes mellitus Type 2 for over ten (10) years and admitted with antibiotic-induced diarrhea 24 hours ago.
• C. An elderly client with a history of hypertension, hypercholesterolemia, and lupus, and was admitted with Stevens-Johnson syndrome that morning.
• D. An adolescent with a positive HIV test and admitted for acute cellulitis of the lower leg 48 hours ago.

Correct answer: A

Rationale: The best candidate for discharge during a need for emergency room availability is a stable patient with a chronic condition who is familiar with their care. In this scenario, the middle-aged client in option A, who has been ventilator dependent for over seven years and admitted with bacterial pneumonia five days ago, is most suitable for discharge. This client is likely stable and can continue medication therapy at home, making them the most appropriate choice for discharge at this time. Choice B should not be the priority for discharge as the young adult with diabetes mellitus Type 2 admitted with antibiotic-induced diarrhea 24 hours ago may need further monitoring and management of their condition. Choice C, the elderly client with multiple comorbidities and admitted with Stevens-Johnson syndrome on the same day, is not a suitable candidate for immediate discharge as they may require ongoing medical attention and observation. Choice D, the adolescent with a positive HIV test and admitted for acute cellulitis of the lower leg 48 hours ago, should not be discharged first as acute cellulitis may require continued treatment and monitoring, especially in the context of a positive HIV status.

4. Efforts by healthcare facilities to reduce the incidence of hospital-acquired infections (HAIs) include an awareness of which of the following?

• A. The CDC requires all states to report HAI rates from each hospital.
• B. Ensure that the restraints are tied to the side rails.
• C. The gastrointestinal tract is a common site for HAIs.
• D. Joint Commission considers death or serious injury from HAIs a sentinel event.

Correct answer: D

Rationale: Efforts to reduce hospital-acquired infections (HAIs) involve being aware that the Joint Commission considers death or serious injury resulting from HAIs a sentinel event, which must be reported. While more than 20 states require reporting of HAI rates to the CDC, it is not a nationwide CDC requirement. The gastrointestinal tract is not a specific common site for HAIs; rather, bacteria are the primary cause. Ensuring restraints are properly secured is important for patient safety but not directly related to reducing HAIs.

5. Cheryl M. has a serious swallowing disorder. She has asked you for a glass of water. The doctor has ordered honey thickness liquids for her. Water is not a honey thickness liquid. It is much thinner. What should you do?

• A. Tell the resident that she cannot have water.
• B. Give her applesauce instead of the water.
• C. Tell Cheryl that she is NPO until midnight.
• D. Thicken the water and give it to her.

Correct answer: D

Rationale: You can give Cheryl the water that she has requested; however, since water is not a honey-thick liquid as ordered by the doctor, you must thicken it with a commercial thickener before giving it to her. This will ensure that the water is at the appropriate consistency for her swallowing disorder. Choices A, B, and C are incorrect: A) Telling the resident she cannot have water is not the best course of action without attempting to modify it first. B) Giving her applesauce instead of water does not address the specific request for water. C) Placing Cheryl on NPO status until midnight is unnecessary and does not address her immediate request for water.

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