Nursing Elites

1. During an examination, a nurse notices a draining ulceration on a patient's lower leg. What is the most appropriate action in this situation?

• A. Wash hands and then contact the physician.
• B. Continue to examine the ulceration and then wash hands.
• C. Wash hands, put on gloves, and continue with the examination of the ulceration.
• D. Wash hands, proceed with the rest of the physical examination, and perform the examination of the leg ulceration last.

Correct answer: C

Rationale: In this scenario, the most appropriate action is to wash hands, put on gloves, and then continue examining the ulceration. Wearing gloves is crucial when there is a possibility of contact with body fluids, as in the case of a draining ulceration. Contacting the physician is not necessary at this point; the immediate focus should be on proper infection control by washing hands and wearing gloves. Changing the order of the examination is not recommended as it is important to follow a systematic approach to avoid missing any crucial assessments.

2. A client who complains of nausea and seems anxious is admitted to the nursing unit. The nurse should take which of the following actions regarding completion of the admission interview?

• A. Help the client to get settled and conduct the interview the next morning when the client is rested
• B. Conduct the interview immediately, directing the majority of the questions to the client
• C. Conduct the interview as soon as uninterrupted time is available to address the client's concerns
• D. Ask the charge nurse to interview the client while the admitting nurse calls the doctor for anti-nausea and anti-anxiety medication

Correct answer: C

Rationale: When dealing with a client who is experiencing nausea and anxiety, it is important to promptly conduct the admission interview to address their concerns. This allows for the collection of accurate data while attending to the client's immediate needs. Delaying the interview until the next morning (Choice A) may not be in the best interest of the client as timely assessment and intervention are essential. Directing questions to the client's spouse (Choice B) may not provide accurate information from the client themselves. Asking another nurse to conduct the interview while administering medications (Choice D) does not prioritize building a therapeutic relationship with the client, which is crucial in addressing their concerns and providing holistic care.

3. When cleansing the genital area during perineal care, the nurse should _____________.

• A. cleanse the penis with a circular motion starting from the base and moving toward the tip.
• B. replace the foreskin after it has been pushed back to cleanse an uncircumcised penis.
• C. cleanse the rectal area first and then clean the patient's genital area.
• D. use the same area on the washcloth for each washing and rinsing stroke for a female resident.

Correct answer: B

Rationale: During perineal care, when cleansing the genital area of an uncircumcised male patient, it is crucial to retract the foreskin to clean the area underneath. This helps in the removal of smegma, a substance that can accumulate and lead to bacterial growth and infection if not cleaned properly. The foreskin should then be replaced back to its original position after cleaning to ensure proper hygiene and prevent any potential complications. Choices A, C, and D are incorrect because they do not address the specific care required for an uncircumcised penis, which involves retracting and replacing the foreskin.

4. A patient is seen in the clinic for reports of "fainting episodes that started last week."? How would the nurse proceed with the examination?

• A. Blood pressure readings are taken in both arms and thighs.
• B. The patient is assisted to a lying position, and their blood pressure is taken.
• C. The patient's blood pressure is recorded in lying, sitting, and standing positions.
• D. The patient's blood pressure is recorded in lying and sitting positions; these numbers are then averaged to obtain a mean blood pressure.

Correct answer: C

Rationale: When a patient reports fainting episodes, it is crucial to assess for orthostatic hypotension. If the nurse suspects volume depletion, the patient has hypertension, is on antihypertensive medications, or has a history of fainting or syncope, blood pressure readings should be taken in three positions: lying, sitting, and standing. This assessment helps detect orthostatic hypotension, which can provide valuable information about the patient's condition. Taking blood pressure readings in multiple positions allows for a comprehensive evaluation of possible postural changes in blood pressure. Choices A, B, and D are incorrect because they do not cover the necessary positions to assess for orthostatic hypotension effectively.

5. According to the American Heart Association standards, high-quality CPR for an adult includes all of the following EXCEPT:

• A. Push hard
• B. Push fast
• C. Allow chest recoil between compressions
• D. Pause CPR as each drug is administered

Correct answer: D

Rationale: High-quality CPR for adults should not be paused for drug administration. The correct CPR technique involves pushing hard and fast, at a rate of at least 100 compressions per minute and to a depth of at least 2 inches. It is also essential to allow chest recoil between compressions to enable proper blood circulation. Pausing CPR for drug administration would delay the delivery of continuous chest compressions, which are crucial for maintaining blood flow and oxygenation during cardiac arrest.

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