Nursing Elites

1. The Rule of Nines is used to:

• A. determine the amount of the body surface that has been burned
• B. assess the level of oxygen saturation in a body that has been burned.
• C. determine the level of tissue damage that has occurred in a burn.
• D. None of the above.

Correct answer: A

Rationale: The Rule of Nines is used to assess the amount of body surface that has been burned. Most body areas are divided out based on 9%, with the exception of the genitalia, which is only 1%.

2. What is the anatomic structure located in the middle of the heart that separates the right and left ventricles?

• A. Septum
• B. Sputum
• C. Separator
• D. None of the above

Correct answer: A

Rationale: The correct answer is the septum. The septum is a structure located in the middle of the heart that separates the right and left ventricles. It plays a crucial role in maintaining the separation between the two ventricles to ensure efficient blood flow. The other choices, 'Sputum' and 'Separator,' are incorrect as they do not refer to the anatomic structure in the heart that serves this specific function. 'Sputum' is a term used to describe phlegm or mucus, not an anatomical structure, and 'Separator' is a generic term that does not specifically identify the cardiac structure mentioned in the question.

3. Which of the following is an example of emotional neglect?

• A. A slap to the person's hand
• B. Threatening the person
• C. Ignoring and isolating a person
• D. Leaving a patient soiled for hours

Correct answer: C

Rationale: The correct answer is ignoring and isolating a person. Emotional neglect involves failing to meet the emotional needs of individuals, which can include ignoring their feelings and isolating them. Choices A, B, and D involve physical aggression, verbal threats, and neglect of physical care, respectively. These actions may be forms of abuse or neglect, but they do not specifically relate to emotional neglect as described in the question.

4. The nurse is assessing children in a pediatric clinic. Which statement is true regarding the measurement of blood pressure in children?

• A. Blood pressure guidelines for children are based on age.
• B. Phase II Korotkoff sounds are the best indicator of systolic blood pressure in children.
• C. Using a Doppler device is recommended for accurate blood pressure measurements until adolescence.
• D. The disappearance of phase V Korotkoff sounds can be used for the diastolic reading in children.

Correct answer: D

Rationale: The disappearance of phase V Korotkoff sounds can be used for the diastolic reading in children, as well as in adults. Blood pressure guidelines for children are based on more than just age, but also sex and height. Phase I Korotkoff, not Phase II, is the best indicator of systolic blood pressure. The true statement regarding the measurement of blood pressure in children is that the disappearance of phase V Korotkoff sounds can be used for the diastolic reading in children, as well as in adults.

5. Which of these statements is true regarding the use of Standard Precautions in the healthcare setting?

• A. Standard Precautions apply to all body fluids, except sweat.
• B. Alcohol-based hand rub should be used if hands are not visibly dirty.
• C. Standard Precautions are intended for use with all patients, regardless of their risk or presumed infection status.
• D. Standard Precautions are to be used only when non-intact skin, excretions containing visible blood, or expected contact with mucous membranes are present.

Correct answer: C

Rationale: Standard Precautions are designed to reduce the risk for transmission of microorganisms from both recognized and unrecognized sources. They are intended for use with all patients, regardless of their risk or presumed infection status. Standard Precautions apply to all body fluids, secretions, and excretions except sweat - whether or not they contain visible blood, non-intact skin, or mucous membranes. Hands should be washed with soap and water if visibly soiled with blood or body fluids. Alcohol-based hand rubs can be used if hands are not visibly soiled. Choice A is incorrect because Standard Precautions apply to all body fluids, secretions, and excretions except sweat. Choice B is incorrect because alcohol-based hand rub should be used when hands are not visibly dirty. Choice D is incorrect because Standard Precautions are not limited to situations involving non-intact skin, excretions with visible blood, or expected mucous membrane contact.

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