Nursing Elites

1. Which of the following is a fat-soluble vitamin?

• A. Vitamin C
• B. Vitamin D
• C. Vitamin B-6
• D. Riboflavin

Correct answer: B

Rationale: The correct answer is Vitamin D. Fat-soluble vitamins are those that can be stored in the body, allowing excess amounts to be stored for later use. While this storage ability can help prevent deficiencies, it also poses a risk of toxicity. The fat-soluble vitamins are A, E, D, and K. Choice A, Vitamin C, is water-soluble, not fat-soluble. Choice C, Vitamin B-6, and Choice D, Riboflavin, are also water-soluble vitamins and not fat-soluble.

2. A 4-month-old child is at the clinic for a well-baby checkup and immunizations. Which of these actions is most appropriate when the nurse is assessing an infant's vital signs?

• A. The infant's radial pulse should be palpated, and the nurse should notice any fluctuations resulting from activity or exercise.
• B. The nurse should auscultate an apical rate for 1 minute and then assess for any normal irregularities, such as sinus dysrhythmia.
• C. The infant's blood pressure should be assessed by using a stethoscope with a large diaphragm piece to hear the soft muffled Korotkoff sounds.
• D. The infant's chest should be observed and the respiratory rate counted for 1 minute; the respiratory pattern may vary significantly.

Correct answer: B

Rationale: The nurse auscultates an apical rate, not a radial pulse, with infants and toddlers. The pulse should be counted by listening to the heart for 1 full minute to account for normal irregularities, such as sinus dysrhythmia. Children younger than 3 years of age have such small arm vessels; consequently, hearing Korotkoff sounds with a stethoscope is difficult. The nurse should use either an electronic blood pressure device that uses oscillometry or a Doppler ultrasound device to amplify the sounds. An infant's respiratory rate should be assessed by observing the infant's abdomen, not chest, because an infant's respirations are normally more diaphragmatic than thoracic. The nurse should auscultate an apical heart rate, not palpate a radial pulse, with infants and toddlers.

3. What technique would the nurse use to accurately assess a rectal temperature in an adult?

• A. Use a lubricated blunt tip thermometer.
• B. Insert the thermometer 2 to 3 inches into the rectum.
• C. Leave the thermometer in place for up to 8 minutes if the patient is febrile.
• D. Wait 2 to 3 minutes if the patient has recently smoked a cigarette.

Correct answer: A

Rationale: To accurately assess a rectal temperature in an adult, a nurse should use a lubricated rectal thermometer with a short, blunt tip. The thermometer is inserted only 2 to 3 cm (1 inch) into the rectum and left in place for 2 minutes. Choice B is incorrect as inserting the thermometer 2 to 3 inches would be too deep and inaccurate. Choice C is incorrect as leaving the thermometer in place for up to 8 minutes is unnecessary and can cause discomfort. Choice D is incorrect as smoking a cigarette does not impact rectal temperatures.

4. Which of the following items of subjective client data would be documented in the medical record by the nurse?

• A. Client's face is pale
• B. Cervical lymph nodes are palpable
• C. Nursing assistant reports client refused lunch
• D. Client feels nauseated

Correct answer: D

Rationale: The correct answer is 'Client feels nauseated.' Subjective data refers to the client's sensations, feelings, and perception of their health status. It can only be reported by the client as it is based on their personal experiences. The feeling of nausea is a subjective symptom that the client experiences and can provide insight into their health condition. Choices A and B represent objective data, as they describe observable or measurable findings that can be detected by the nurse. Choice C involves information reported by someone other than the client, making it indirect and not purely subjective.

5. While measuring a patient's blood pressure, which factor influences a patient's blood pressure?

• A. Pulse rate
• B. Pulse pressure
• C. Vascular output
• D. Peripheral vascular resistance

Correct answer: D

Rationale: When measuring a patient's blood pressure, it is important to consider various factors that influence blood pressure. Peripheral vascular resistance plays a crucial role in regulating blood pressure. The level of blood pressure is affected by factors such as cardiac output, peripheral vascular resistance, volume of circulating blood, viscosity, and elasticity of the vessel walls. Pulse rate (Choice A) refers to the number of heartbeats per minute and is not a primary factor influencing blood pressure. Pulse pressure (Choice B) is the difference between systolic and diastolic blood pressure and does not directly impact blood pressure regulation. Vascular output (Choice C) is not a recognized term in blood pressure regulation and is not a primary factor affecting blood pressure.

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