Nursing Elites

1. When providing endotracheal suctioning, for how long should the nurse suction the endotracheal tube of an intubated client on a ventilator at a time?

• A. Five seconds or less
• B. Ten seconds or less
• C. At least 30 seconds
• D. No longer than 60 seconds

Correct answer: B

Rationale: When providing endotracheal suctioning, the nurse should suction for no longer than ten seconds at a time. Suctioning for longer than ten seconds may cause hypoxia or bronchospasm. Extended suctioning may also place the client at risk of injury to the bronchial and tracheal structures. Choices C and D suggest prolonged suctioning durations that can lead to adverse effects on the client. Choice A, suctioning for five seconds or less, may not be adequate to clear secretions effectively, making choice B the most appropriate duration for safe and efficient suctioning in this scenario.

2. When providing culturally competent care, nurses must incorporate cultural assessments into their health assessments. Which statement is most appropriate to use when initiating an assessment of cultural beliefs with an older American Indian patient?

• A. "Are you of the Christian faith?"?
• B. "Do you want to see a medicine man?"?
• C. "How often do you seek help from medical providers?"?
• D. "What cultural or spiritual beliefs are important to you?"?

Correct answer: D

Rationale: The nurse needs to assess the cultural beliefs and practices of the patient and should ask questions in a way that communicates acceptance of their beliefs and allows for open communication. Therefore, the most appropriate question to initiate an assessment of cultural beliefs with an older American Indian patient is "What cultural or spiritual beliefs are important to you?"? This question shows respect for the patient's beliefs and encourages them to share relevant information. Asking if they are of the Christian faith does not promote open communication and may not reflect the patient's actual beliefs. While some American Indians may seek assistance from a medicine man or shaman, it is not appropriate to make assumptions without direct input from the patient. Asking how often they seek help from medical providers is not directly related to understanding their cultural beliefs and may not provide relevant insights for culturally competent care.

3. An Asian-American woman is experiencing diarrhea, which is believed to be "cold"? or "yin."? What should the nurse recognize that the woman may likely try to treat it?

• A. Foods that are "hot"? or "yang"?
• B. Readings and Eastern medicine meditations
• C. High doses of medicines believed to be "cold"?
• D. No treatment because diarrhea is an expected part of life.

Correct answer: A

Rationale: In this scenario, the Asian-American woman is believed to be experiencing diarrhea due to a "cold"? or "yin"? imbalance. According to the yin/yang theory, yang represents heat and yin represents cold. Therefore, to balance the cold nature of the diarrhea, the woman may try to treat it by consuming foods that are considered "hot"? or "yang"?. This aligns with the concept that cold foods are eaten with a hot illness, and hot foods are eaten with a cold illness. Choices B, C, and D do not align with the yin/yang theory and are not relevant to addressing the imbalance associated with the cold nature of the diarrhea.

4. Which desired outcome written by the nurse is correctly written and measurable?

• A. Client will have a normal bowel pattern by April 2
• B. The client will lose 4 lbs. within the next 2 weeks
• C. The nurse will provide skin care at least 3 times each day
• D. The client will breathe better after resting for 10 minutes

Correct answer: B

Rationale: An outcome statement must describe the observable client behavior that should occur in response to the nursing interventions. It consists of a subject, action verb, conditions under which the behavior is to be performed, and the level at which the client will perform the desired behavior. Option B is correctly written and measurable as it includes all the required elements: subject (client), action verb (lose), conditions (within the next 2 weeks), and the level at which the behavior should occur (4 lbs.). Option A lacks the conditions and a specific level, making it not measurable. Option C is a nursing intervention rather than a client goal. Option D does not provide a specific level at which the client should perform the desired behavior, making it not measurable as well.

5. In the Gram Stain procedure, which component acts as the mordant?

• A. Crystal violet
• B. Methyl alcohol
• C. Iodine
• D. Safranin

Correct answer: C

Rationale: In the Gram Stain procedure, the mordant is Gram's Iodine. The purpose of the mordant is to form a complex with the crystal violet, enhancing its ability to bind to the cell wall. Crystal violet is actually the primary stain used in the Gram Stain procedure to initially color all cells. Methyl alcohol is the decolorizer that removes the crystal violet from certain cell types. Safranin is the counterstain used to stain those cells that did not retain the crystal violet stain after the decolorization step.

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