Nursing Elites

1. 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.

2. 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.

3. During which part of the client interview would it be best for the nurse to ask, 'What's the weather forecast for today?'

• A. Introduction
• B. Body
• C. Closing
• D. Orientation

Correct answer: A

Rationale: Asking about the weather initiates the social or introductory phase of the interview, allowing the nurse to establish rapport with the client at the beginning. This question can help assess the client's mental status and set a friendly tone. In the body phase, the client responds to the nurse's inquiries, while during the closing phase, either the nurse or the client concludes the interview. Therefore, the best time to ask about the weather forecast is during the introduction phase to facilitate a positive start to the interaction.

4. To collect timely, specific information, the nurse is most likely to ask which of the following questions?

• A. Would you describe what you are feeling?
• B. How are you today?
• C. What would you like to talk about?
• D. Where does it hurt?

Correct answer: A

Rationale: The correct answer is, 'Would you describe what you are feeling?' This open-ended question prompts the patient to provide subjective data, offering specific information about their current health status and human responses. This information can help identify actual or potential health issues. Choices B and C are more likely to yield general, nonspecific information. Choice D may lead to a brief response or nonverbal indication of pain location. A more effective approach to gather specific information about pain would be to ask, 'Can you describe any pain you are experiencing?'

5. How many cc are there in 25 ounces?

• A. 250
• B. 500
• C. 750
• D. 1000

Correct answer: C

Rationale: To convert ounces to cc, we know that there are 30 cc in 1 ounce. Therefore, to find out how many cc are in 25 ounces, we multiply 30 cc/ounce by 25 ounces which equals 750 cc. This makes choice C, 750, the correct answer. Choices A, B, and D are incorrect as they do not correctly convert ounces to cc.

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