Nursing Elites

1. Which of the following microorganisms are considered normal body flora?

• A. staphylococcus on the skin
• B. streptococcus in the nares
• C. candida albicans in the vagina
• D. pseudomonas in the blood

Correct answer: A

Rationale: Staphylococcus is considered normal body flora as it is commonly found on the skin, being a part of the normal microbiota. While streptococcus in the nares can be part of the normal flora of the upper respiratory tract, it is not as common or as widespread as staphylococcus on the skin. Candida albicans in the vagina is not considered normal flora; it is a common opportunistic pathogen in the vagina. Pseudomonas in the blood is also not considered normal body flora; pseudomonas is not typically found in the blood as part of the normal microbiota.

2. In an obstetrical emergency, which of the following actions should the nurse perform first after the baby delivers?

• A. Place extra padding under the mother to absorb blood from the delivery.
• B. Cut the umbilical cord using sterile scissors.
• C. Suction the baby's mouth and nose.
• D. Wrap the baby in a clean blanket to preserve warmth.

Correct answer: C

Rationale: In an obstetrical emergency, the immediate priority after the baby delivers is to clear the baby's airway by suctioning the mouth and nose to ensure effective breathing. This action helps prevent potential complications like meconium aspiration. Cutting the umbilical cord, wrapping the baby in a blanket, or placing extra padding under the mother can follow once the baby's airway is clear. Therefore, suctioning the baby's mouth and nose is the most critical and time-sensitive intervention in this scenario. Placing extra padding under the mother is not the immediate priority as ensuring the baby's airway is clear. Cutting the umbilical cord and wrapping the baby in a clean blanket are important but can wait until after ensuring the baby's breathing is not compromised.

3. How far should the enema tube be inserted for a client to have a flatus-reducing enema?

• A. 4 inches.
• B. 6 inches.
• C. 2 inches.
• D. 8 inches.

Correct answer: A

Rationale: The correct answer is to insert the enema tube 4 inches. Enema tubing must be passed beyond the internal sphincter, which is typically around 4 inches in an adult. Inserting the tube only 2 inches is not far enough to reach this point. On the other hand, inserting the tube 6 or 8 inches is too far and might cause trauma to the bowel, which is unnecessary for a flatus-reducing enema. Therefore, the correct insertion depth of the enema tube is crucial to ensure effectiveness and safety in providing the intended treatment.

4. Which of the following is not considered one of the five rights of medication administration?

• A. client
• B. drug
• C. dose
• D. routine

Correct answer: D

Rationale: The five rights of medication administration are dose, client, drug, route, and time. The correct answer is 'routine' as it is not commonly recognized as one of the essential rights in medication administration. Choice A, client, is necessary to ensure the right medication is administered to the right individual. Choice B, drug, is crucial to confirm the correct medication is given. Choice C, dose, is essential to ensure the right amount of medication is administered. Choice D, routine, is not typically included in the five rights of medication administration and is therefore the correct answer.

5. Which of the following foods should be avoided by clients who are prone to developing heartburn as a result of gastroesophageal reflux disease (GERD)?

• A. lettuce
• B. eggs
• C. chocolate
• D. butterscotch

Correct answer: C

Rationale: The correct answer is chocolate. Ingestion of chocolate can reduce lower esophageal sphincter (LES) pressure, leading to reflux and clinical symptoms of GERD. Lettuce and eggs do not significantly affect LES pressure, making them less likely to trigger GERD symptoms. Butterscotch, like lettuce and eggs, does not have a notable effect on LES pressure, so it is not as likely to worsen GERD symptoms as chocolate. Therefore, chocolate is the food to be avoided by clients prone to heartburn due to GERD.

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