Nursing Elites

1. When reinforcing teaching about self-care with a patient who has pelvic inflammatory disease and does not speak English, what action by the nurse is appropriate?

• A. Provide written instructions in English.
• B. Use family members as translators.
• C. Seek assistance from a facility-approved interpreter.
• D. Use online translation tools.

Correct answer: C

Rationale: When communicating with a patient who does not speak English, it is crucial to seek assistance from a facility-approved interpreter. Using family members as translators can lead to inaccuracies, breaches in confidentiality, and discomfort for the patient. Online translation tools may not provide accurate or context-specific translations, which can result in misunderstandings. Providing written instructions in English would not be effective if the patient does not understand the language.

2. A nurse is preparing to administer an intramuscular injection to an adult client. At what angle should the nurse administer the medication using the ventrogluteal site?

• A. 90-degree angle
• B. 60-degree angle
• C. 75-degree angle
• D. 45-degree angle

Correct answer: A

Rationale: The correct answer is A: 90-degree angle. The ventrogluteal site is preferred for intramuscular injections because it is away from major nerves and blood vessels. Administering the injection at a 90-degree angle ensures that the medication reaches deep into the muscle tissue, allowing for proper absorption of the drug. Choice B, 60-degree angle, is incorrect as it is not the recommended angle for the ventrogluteal site. Choice C, 75-degree angle, and Choice D, 45-degree angle, are also incorrect as they are not the appropriate angles for administering an intramuscular injection using the ventrogluteal site.

3. A nurse is preparing to administer a measles, mumps, rubella (MMR) immunization to a child. Which is a contraindication for this vaccine?

• A. Recent blood transfusion
• B. Allergy to penicillin
• C. Minor acute illness
• D. Low-grade fever

Correct answer: A

Rationale: The correct answer is A: Recent blood transfusion. A recent blood transfusion can interfere with the effectiveness of the MMR vaccine, making it a contraindication. Choice B, allergy to penicillin, is not a contraindication for the MMR vaccine. Choice C, minor acute illness, is not a contraindication unless the child has a moderate to severe illness. Choice D, low-grade fever, is not a contraindication as long as the child does not have a moderate to severe febrile illness.

4. A nurse is assessing a newborn who is 10 hours old. Which of the following findings should the nurse report to the provider?

• A. Axillary temperature 36.5°C (97.7°F)
• B. Nasal flaring
• C. Heart rate 158/min
• D. One void since birth

Correct answer: B

Rationale: Nasal flaring can indicate respiratory distress in a newborn, which is a critical finding requiring immediate attention. This may suggest an issue with breathing or lung function. Reporting nasal flaring promptly allows the provider to assess and intervene to ensure the newborn's respiratory status is stable. Choices A, C, and D are within normal parameters for a 10-hour-old newborn and do not indicate an immediate concern. An axillary temperature of 36.5°C (97.7°F) is within the normal range for a newborn. A heart rate of 158/min is typical for a newborn, and one void since birth is an expected finding at this early stage.

5. A nurse is preparing to perform a sterile dressing change for a client who has a surgical wound. Which of the following actions should the nurse take to prevent contamination during the dressing change?

• A. Use sterile gloves only as necessary
• B. Restart the procedure if the sterile solution splashes onto the sterile field while pouring the solution into the dressing tray
• C. Keep the dressing tray on a nearby surface
• D. Avoid speaking during the procedure

Correct answer: B

Rationale: The correct action to prevent contamination during a sterile dressing change is to restart the procedure if the sterile solution splashes onto the sterile field while pouring the solution into the dressing tray. Any contact with the sterile field by non-sterile items makes the field contaminated and requires restarting the procedure to maintain sterility. Choice A is incorrect because sterile gloves should always be used during a sterile procedure to prevent contamination. Choice C is incorrect as the dressing tray should be placed on a sterile surface, not on the client's bed, to maintain sterility. Choice D is also incorrect as talking during the procedure does not necessarily lead to contamination if proper aseptic technique is maintained.

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