Nursing Elites

1. Which nursing intervention is the highest priority for a client at risk for falls in a hospital setting?

• A. Keep all of the side rails up
• B. Review prescribed medications
• C. Complete the "get up and go"? test
• D. Place the bed in the lowest position

Correct answer: D

Rationale: The highest priority nursing intervention for a client at risk for falls in a hospital setting is to place the bed in the lowest position. This action ensures that the client falls the shortest distance, reducing the risk of injury. Keeping all side rails up (Option A) may lead to a fall with injury, as the client might attempt to get over the rail and fall from a higher distance. Reviewing prescribed medications (Option B) is important as certain medications can increase the risk of falling, but it is not the best answer as it is not applicable to all clients. Completing the "get up and go"? test (Option C) can help assess a client's risk for falling but does not directly prevent injury.

2. Which of the following vital signs can be expected in a child that is afebrile?

• A. Rectal Temp of 100.9 degrees F.
• B. Oral Temp of 38 degrees C.
• C. Axillary Temp of 98.6 degrees F.
• D. All of the above are incorrect.

Correct answer: C

Rationale: The correct answer is the axillary temperature of 98.6 degrees F. Afebrile means without a fever, and an axillary temperature, which is taken in the armpit, is considered normal at 98.6 degrees F. Choice A is incorrect as a rectal temperature of 100.9 degrees F indicates a fever. Choice B is incorrect as an oral temperature of 38 degrees C is also indicative of a fever. Choice D is incorrect as not all options are wrong; only choices A and B are incorrect for an afebrile child.

3. 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.

4. Your elderly patient has a temperature of 98.5 degrees. Is there anything else that a nurse should do, in addition to documenting this temperature?

• A. No, this temperature is within normal limits.
• B. No, this temperature is normally hyperthermic.
• C. Yes, this temperature is highly hyperthermic.
• D. Yes, this temperature is highly hypothermic.

Correct answer: A

Rationale: No, there is nothing else that a nurse should do. A temperature of 98.5 degrees for an elderly patient falls within normal limits. Other choices are incorrect because the temperature is not hyperthermic (abnormally high) or hypothermic (abnormally low), making choices B, C, and D inaccurate responses in this scenario.

5. A nurse is preparing to insert a small-bore nasogastric feeding tube for a client's enteral feedings. In which method does the nurse measure the correct length of the tube?

• A. From the tip of the nose to the xiphoid process
• B. From the tip of the nose to the earlobe to the xiphoid process
• C. From the earlobe to the xiphoid process
• D. From the tip of the nose to the earlobe to the umbilicus

Correct answer: B

Rationale: When preparing to insert a nasogastric tube, the nurse must measure the correct length to ensure that the end of the tube will be in the correct position in the stomach. The accurate method to measure the length is from the tip of the nose to the earlobe to the xiphoid process. This length ensures that the end of the tube reaches the stomach, avoiding placement in the small intestine or esophagus. Choice A is incorrect as it does not include the earlobe, which is essential for accurate measurement. Choice C is incorrect because measuring from the earlobe alone does not provide the correct length for positioning in the stomach. Choice D is incorrect as it includes the umbilicus, which is not the appropriate landmark for measuring the length of a nasogastric tube intended for stomach placement.

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