Nursing Elites

1. In what order should the nurse perform the steps of a surgical hand scrub prior to entering the operating room?

• A. Rinse from the fingertips to the elbow
• B. Scrape under the nails with a nail pick
• C. Use a soapy brush to scrub the hands
• D. Cleanse the arm with a lathered brush

Correct answer: B

Rationale: The correct order for performing a surgical hand scrub is to first scrape under the nails with a nail pick, then scrub the hands using a soapy brush, cleanse the arms, and finally rinse. This sequence ensures thorough cleaning and minimizes the risk of contamination. Choice A is incorrect because rinsing should be the final step, not the first. Choice C is incorrect as scrubbing the hands comes after scraping under the nails. Choice D is incorrect as cleansing the arms should follow hand scrubbing, not precede it.

2. When caring for a client with diabetes insipidus (DI), it is most important for the nurse to include frequent assessment for which conditions in the client’s plan of care?

• A. Dry mucous membranes, hypotension
• B. Decreased appetite, headache
• C. Nausea and vomiting, muscle weakness
• D. Elevated blood pressure, petechiae

Correct answer: A

Rationale: Dry mucous membranes and hypotension are key indicators of dehydration in clients with diabetes insipidus. The excessive urination associated with DI can lead to fluid loss, resulting in dehydration. Therefore, monitoring for signs such as dry mucous membranes and hypotension is crucial to assess the client's hydration status. Choices B, C, and D are not directly related to the characteristic symptoms of DI and are less relevant in the context of this condition. Decreased appetite and headache (Choice B) are nonspecific symptoms that may occur in various conditions. Nausea, vomiting, and muscle weakness (Choice C) are not typical manifestations of DI. Elevated blood pressure and petechiae (Choice D) are not commonly associated with DI; instead, hypotension is more commonly observed due to volume depletion.

3. The nurse is measuring the output of an infant admitted for vomiting and diarrhea. During a 12-hour shift, the infant drinks 4 ounces of Pedialyte, vomits 25 ml, and voids twice. The dry diaper weighs 105 grams. Which computer documentation should the nurse enter in the infant’s record?

• A. Subtract vomitus from 120 ml Pedialyte, then document 95 ml oral intake.
• B. Compare the difference between the infant’s current weight and admission weight.
• C. Document on the flow sheet that the infant voided twice and vomited 25 ml.
• D. Calculate the difference in wet and dry diapers and document 80 ml urine.

Correct answer: C

Rationale: The correct answer is to document on the flow sheet that the infant voided twice and vomited 25 ml. This choice accurately reflects the need for accurate documentation of intake and output, essential for monitoring the infant's hydration status. Choice A is incorrect because the oral intake should not be calculated by subtracting vomitus from the oral intake. Choice B is incorrect because it does not address the specific documentation related to the infant's output. Choice D is incorrect as it focuses on calculating urine output based on diaper weight, which is not the primary concern in this scenario.

4. A female client tells the clinic nurse that she has doubts about binge eating but cannot make herself vomit after meals. Which action by the nurse provides data to support the suspected diagnosis of bulimia?

• A. Ask the client to complete a food diary for the last 3 days
• B. Review the client’s lab data to determine her TSH, T3, and T4 levels
• C. Interview the client about her use of laxatives and diuretics
• D. Encourage the client to describe her daily exercise regimen

Correct answer: C

Rationale: Inquiring about laxative and diuretic use helps confirm bulimia as these are common behaviors associated with the disorder. Asking the client to complete a food diary (Choice A) may provide information on eating patterns but does not directly support the diagnosis of bulimia. Reviewing lab data (Choice B) for thyroid function is not specific to bulimia. Encouraging the client to describe her exercise regimen (Choice D) may be relevant for overall health assessment but does not specifically address bulimia symptoms.

5. An older male resident of a long-term care facility has been scratching his legs for the past 2 days. Which intervention should the nurse implement?

• A. Explain the importance of bathing or showering daily
• B. Encourage fluid intake of at least 2,000 ml daily
• C. Keep the legs covered as much as possible
• D. Apply emollient to the affected area at least twice daily

Correct answer: D

Rationale: The correct intervention for the nurse to implement in this scenario is to apply emollient to the affected area at least twice daily. This is because applying emollients helps address dry skin, which is a common cause of itching in older adults. Explaining the importance of bathing or showering daily (Choice A) may be helpful for general hygiene but may not specifically address the itching. Encouraging fluid intake (Choice B) and keeping the legs covered (Choice C) are not directly related to addressing the itching caused by dry skin.

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