Nursing Elites

1. In what order should the PN implement these steps to provide wound care? (Place in correct order.)

• A. Don procedure gloves
• B. Remove the dressing
• C. Apply prescribed medications to the wound
• D. All of the Above

Correct answer: D

Rationale: The correct answer is 'D - All of the Above.' The PN should first don procedure gloves to maintain aseptic technique, then remove the dressing to assess the wound, and finally apply prescribed medications to the wound. This sequence ensures that non-sterile tasks like donning gloves are done before sterile tasks like applying medications, reducing the risk of wound contamination. Choices A, B, and C are all essential steps in providing effective wound care.

2. Which of the following is the most effective way to prevent the spread of infection in a healthcare setting?

• A. Using sterile gloves
• B. Wearing a face mask
• C. Performing hand hygiene
• D. Using disposable equipment

Correct answer: C

Rationale: Performing hand hygiene is the most effective way to prevent the spread of infection in a healthcare setting. Hand hygiene helps remove pathogens that could be transmitted through direct contact, making it a crucial practice in infection control. While using sterile gloves and disposable equipment are important in certain situations, they do not address the potential transmission of pathogens through direct contact, unlike hand hygiene. Wearing a face mask is important for respiratory precautions but may not be as effective as hand hygiene in preventing the spread of infections through direct contact.

3. Which assessment finding would most likely indicate a complication of enteral tube feeding?

• A. Abdominal distension
• B. Weight gain
• C. Decreased bowel sounds
• D. Diarrhea

Correct answer: A

Rationale: Abdominal distension in a patient receiving enteral tube feeding may indicate a complication such as intolerance to feeding, delayed gastric emptying, or obstruction. Abdominal distension is a common sign of gastrointestinal issues related to enteral tube feeding. Weight gain is typically an expected outcome if the patient is receiving adequate nutrition. Decreased bowel sounds may indicate decreased motility but are not specific to enteral tube feeding complications. Diarrhea can occur due to various reasons, including infections, medications, or dietary changes, but it is not the most likely indication of a complication in enteral tube feeding.

4. What disorder closely matches Suzy's symptoms?

• A. Antisocial personality disorder
• B. Borderline personality disorder
• C. Schizoid personality disorder
• D. Dissociative Identity Disorder

Correct answer: B

Rationale: Suzy's symptoms are characteristic of Borderline Personality Disorder (BPD). BPD includes instability in relationships, self-image, and emotions, as well as impulsivity and self-harm. Choice A, Antisocial personality disorder, is characterized by a disregard for others' rights and lack of empathy, which does not align with Suzy's symptoms. Schizoid personality disorder, choice C, is characterized by a lack of interest in social relationships, which is not a prominent feature in Suzy's case. Dissociative Identity Disorder, choice D, involves the presence of two or more distinct identities or personality states, which is not reflected in Suzy's symptoms.

5. A nurse is caring for a client with schizophrenia who continues to repeat the last words heard. Which nursing problem should the nurse document in the medical record?

• A. Altered thought processes
• B. Impaired social interaction
• C. Risk for self-directed violence
• D. Disturbed thought processes

Correct answer: D

Rationale: The correct answer is D: Disturbed thought processes. Echolalia, or the repetition of words, is indicative of disturbed thought processes, a common symptom in clients with schizophrenia. Choice A (Altered thought processes) is a more appropriate term than 'Disturbed thought processes' to describe the issue of echolalia. Choice B (Impaired social interaction) is not the best option in this scenario as echolalia is not primarily a social interaction issue. Choice C (Risk for self-directed violence) is not directly related to the symptom described in the question, which is echolalia, indicating a disturbance in thought processes.

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