Nursing Elites

1. Which contraindication should be assessed for prior to administering an immunization to a child?

• A. Mild cold symptoms
• B. Chronic asthma
• C. Depressed immune system
• D. Allergy to eggs

Correct answer: C

Rationale: Before administering immunizations to children, it is crucial to assess for contraindications. A depressed immune system, such as that seen in conditions like HIV or due to chemotherapy, is a significant contraindication. Immunizations may not be safe or effective in children with compromised immune systems. Mild cold symptoms, although not ideal, are not a contraindication for routine immunizations. Chronic asthma, while a consideration, is not a direct contraindication for routine immunizations. Allergy to eggs is a contraindication for specific vaccines, such as influenza vaccine that is grown in eggs, but it is not a contraindication for all immunizations.

2. A nurse is preparing to change a client's dressing for a burn wound on his foot. Which of the following interventions is appropriate for this process?

• A. Wash the wound with cleanser, rinse, and pat dry
• B. Bind the wound tightly, secure with tape, and elevate the foot
• C. Contact the physician after the dressing change is complete
• D. Provide analgesics for the client after the procedure

Correct answer: A

Rationale: When changing the dressing for a burn wound, it is essential to follow appropriate interventions to prevent infection, reduce pain, and support healing. In this scenario, after removing the old dressing, it is crucial to wash the wound gently with a suitable cleanser, rinse the area thoroughly, and then pat it dry. This process helps in maintaining cleanliness, reducing the risk of infection, and providing a conducive environment for healing. Binding the wound tightly (Choice B) can impede circulation and delay healing. Contacting the physician after the dressing change (Choice C) may be necessary in specific situations but is not a standard step in routine dressing changes. Providing analgesics after the procedure (Choice D) is important for pain management but is not directly related to the dressing change itself.

3. Which of the following organs would be described as being located retroperitoneally?

• A. Kidneys
• B. Thymus
• C. Small Intestines
• D. Spleen

Correct answer: A

Rationale: The term 'retroperitoneal' refers to organs positioned behind the peritoneum. The kidneys are retroperitoneal organs, located outside the peritoneal cavity, against the posterior abdominal wall. This positioning provides them with additional protection from external forces due to the surrounding structures. The thymus, small intestines, and spleen are not retroperitoneal organs. The thymus is located in the mediastinum, the small intestines are intraperitoneal, and the spleen is intraperitoneal and located in the left upper quadrant of the abdomen.

4. While auscultating heart sounds, the nurse hears a murmur. Which of these instruments would be used to assess this murmur?

• A. Electrocardiogram
• B. Bell of the stethoscope
• C. Diaphragm of the stethoscope
• D. Palpation with the nurse's palm of the hand

Correct answer: B

Rationale: The correct instrument to assess a murmur while auscultating heart sounds is the bell of the stethoscope. An electrocardiogram is used to measure the heart's electrical activity, not to assess murmurs. Palpation with the nurse's palm of the hand is a method to assess pulses or textures, not heart murmurs. The diaphragm of the stethoscope is typically used for high-pitched sounds like breath, bowel, and normal heart sounds, whereas the bell is more suitable for soft, low-pitched sounds such as murmurs or extra heart sounds.

5. A newly admitted patient with major depression has lost 20 pounds over the past month and has suicidal ideation. The patient has taken an antidepressant medication for 1 week without remission of symptoms. Select the priority nursing diagnosis.

• A. Imbalanced nutrition: Less than body requirements
• B. Chronic low self-esteem
• C. Risk for suicide
• D. Hopelessness

Correct answer: B

Rationale: The priority nursing diagnosis in this scenario is 'Risk for suicide.' When a patient presents with major depression, significant weight loss, suicidal ideation, and lack of symptom improvement despite medication, the immediate concern is to address the risk of suicide. 'Risk for suicide' takes precedence as it involves a direct threat to the patient's life. 'Imbalanced nutrition: Less than body requirements' may be a concern but does not take priority over the risk of suicide. 'Chronic low self-esteem' and 'Hopelessness' are relevant issues in depression but are not as urgent as addressing the immediate risk of suicidal behavior.

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