Nursing Elites

1. The nurse is assessing the vital signs of a 3-year-old patient who appears to have an irregular respiratory pattern. How would the nurse assess this child's respirations?

• A. Respirations should be counted for 1 full minute.
• B. Child's pulse and respirations should be simultaneously checked for 30 seconds and then multiplied by 2.
• C. Child's respirations should be checked for a minimum of 5 minutes to identify any variations in his or her respiratory pattern.
• D. Patient's respirations should be counted for 15 seconds and then multiplied by 4.

Correct answer: A

Rationale: To accurately assess a child's respiratory pattern, the nurse should count respirations for a full minute. This duration provides a comprehensive view of the child's breathing pattern, ensuring abnormalities are not missed. Counting for only 30 seconds may not capture irregularities effectively. Checking respirations for 5 minutes is excessive and unnecessary for a routine assessment. Counting for 15 seconds and multiplying by 4 is not as precise as a full-minute count. Pulse and respirations should not be checked simultaneously; instead, the nurse should count respirations unobtrusively while appearing to take the child's pulse. Therefore, the correct approach is to count the child's respirations for 1 full minute to obtain an accurate assessment.

2. While explaining an illness to a 10-year-old, what should the nurse keep in mind about the cognitive development at this age?

• A. They are able to make simple associations of ideas
• B. They are able to think logically in organizing facts
• C. Interpretation of events originates from their own perspective
• D. Conclusions are based on previous experiences

Correct answer: B

Rationale: At the age of 10, children are in the concrete operations stage according to Piaget. They are capable of mature thought when allowed to manipulate and organize objects. This means they can think logically, organize facts, and understand cause-and-effect relationships. Choices A, C, and D are incorrect. While simple associations of ideas may occur, the key cognitive ability at this stage is the capacity for logical thought and organization of information. Interpretation of events from their own perspective is more characteristic of younger children, and conclusions based on previous experiences are more aligned with older children or adults.

3. You are preparing to admit a patient with a seizure disorder. Which of the following actions can you delegate to an LPN/LVN?

• A. Complete admission assessment.
• B. Set up oxygen and suction equipment.
• C. Place a padded tongue blade at the bedside.
• D. Pad the side rails before the patient arrives.

Correct answer: B

Rationale: The correct answer is to delegate the task of setting up oxygen and suction equipment to the LPN/LVN. This task falls within their scope of practice and can be safely performed by them. Completing the admission assessment (Choice A) typically requires a higher level of assessment and critical thinking, making it more appropriate for a registered nurse. Placing a padded tongue blade at the bedside (Choice C) involves potential airway management, which is a more complex task and should be done by a higher-level provider. Padding the side rails before the patient arrives (Choice D) is a task related to patient safety and should be done by the healthcare team as a whole, not solely delegated to an LPN/LVN.

4. Which type of shock is related to low blood volume?

• A. Psychogenic
• B. Cardiogenic
• C. Anaphylactic
• D. Hemorrhagic

Correct answer: D

Rationale: Hemorrhagic shock, also known as hypovolemic shock, is directly related to low blood volume due to significant blood loss. In hemorrhagic shock, the body's circulating blood volume is reduced, leading to inadequate perfusion of tissues and organs. Psychogenic shock is caused by emotional distress, not blood volume changes. Cardiogenic shock results from heart failure, not low blood volume. Anaphylactic shock is due to a severe allergic reaction, not a reduction in blood volume.

5. The healthcare professional notices that a colleague is preparing to check the blood pressure of a patient who is obese by using a standard-sized blood pressure cuff. How would this likely affect the blood pressure reading?

• A. Yield a falsely low blood pressure
• B. Yield a falsely high blood pressure
• C. Be the same, regardless of cuff size
• D. Vary as a result of the technique of the person performing the assessment

Correct answer: B

Rationale: Using a cuff that is too narrow for an obese patient would likely yield a falsely high blood pressure reading. This occurs because the standard cuff is too small for the arm's circumference, requiring more pressure to compress the artery. A tight cuff can lead to inaccurate and elevated blood pressure readings. Choices A, C, and D are incorrect because using an improperly sized cuff would not yield a falsely low blood pressure, the blood pressure reading does vary with cuff size, and the technique of the person performing the assessment is not the primary factor affecting the reading in this situation.

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