Nursing Elites

1. Which of the following statements, if made by the parents of a newborn, does not indicate a need for further teaching about cord care?

• A. "I should put alcohol on my baby's cord 3-4 times a day."?
• B. "I should put the baby's diaper on so that it covers the cord."?
• C. "I should call the physician if the cord becomes dark."?
• D. "I should wash my hands before and after I take care of the cord."?

Correct answer: A

Rationale: Explanation: Parents should be taught that putting alcohol or other antimicrobials on the cord is no longer recommended for cord care. This can interfere with the natural healing process and may increase the risk of irritation or infection. Washing hands before and after providing cord care is essential to prevent the transfer of pathogens. Placing the baby's diaper below the cord allows it to be exposed to air and promotes drying, reducing the risk of infection. It is normal for the cord to turn dark as it dries, so calling the physician only if the cord becomes red, swollen, or has discharge is appropriate. Therefore, the statement '"I should put alcohol on my baby's cord 3-4 times a day."?' indicates a need for further teaching about cord care.

2. What is the threshold of dextrose concentrations that can safely be administered through a peripheral IV?

• A. Dextrose concentrations below 20% can be safely administered through a peripheral IV; dextrose concentrations above 20% should not be administered through a peripheral IV.
• B. Dextrose concentrations below 5% can be safely administered through a peripheral IV; dextrose concentrations above 5% should not be administered through a peripheral IV.
• C. Dextrose concentrations below 10% can be safely administered through a peripheral IV; dextrose concentrations above 10% should not be administered through a peripheral IV.
• D. Dextrose concentrations above 5% can be safely administered through a peripheral IV; dextrose concentrations below 5% should not be administered through a peripheral IV.

Correct answer: C

Rationale: Dextrose concentrations below 10% are considered safe for administration through a peripheral IV, as concentrations above this threshold can lead to phlebitis, causing inflammation of the vein. Concentrations above 10% should not be administered through a peripheral IV to prevent vein irritation. Choice A is incorrect because concentrations above 20% are too high for a peripheral IV. Choice B is incorrect as dextrose concentrations below 5% are too low to be effective. Choice D is incorrect because the statement is reversed, suggesting that concentrations above 5% are safe, which is not true.

3. When planning for the physical assessment of the woman, the nurse ensures that which occurs?

• A. The woman is examined by a female health care provider.
• B. The woman's husband remains in the examining room at all times.
• C. The woman is examined without any other people in the examining room.
• D. Written permission is obtained from the woman to obtain subjective health data.

Correct answer: A

Rationale: In many cultures, including Muslim, Hindu, and Latino, modesty is important, and exposure of a woman's genitals to men is considered demeaning. To respect the patient's cultural beliefs and modesty, it is best for a female health care provider to perform the examination. This practice helps to ensure the patient's comfort and adherence to cultural norms. Having the woman examined without any other people in the room (Choice C) may not address the cultural sensitivity required for this situation. Having the woman's husband remain in the examining room at all times (Choice B) may not align with the patient's cultural preferences and may cause discomfort. Written permission from the woman to obtain subjective health data (Choice D) is not directly related to ensuring a culturally sensitive physical assessment in this context.

4. A client with massive chest and head injuries is admitted to the ICU from the Emergency Department. All of the following are true except:

• A. The physician in charge of the case is the sole person allowed to decide whether organ donation can occur.
• B. The client's legally responsible party may make the decision for organ donation for the donor if the client is unable to do so.
• C. The organ procurement organization makes the decision regarding which organs to harvest.
• D. The donor (or legally responsible party for the donor), the physician, and the organ-procurement organization are all involved in the process.

Correct answer: A

Rationale: While the physician plays a crucial role in the process of organ donation, they are not the sole decision-maker. The client's legally responsible party may make the decision for organ donation if the client is unable to do so. Additionally, the organ procurement organization is responsible for determining which organs are suitable for donation. Therefore, the statement that the physician in charge is the sole person allowed to decide whether organ donation can occur is incorrect. The correct answer is A. Choices B, C, and D are true statements as they highlight the involvement of the legally responsible party, the organ procurement organization, and the donor/legally responsible party, physician, and organ-procurement organization in the organ donation process respectively.

5. When an elder client asks the nurse whether he will be capable of sexual activity in old age, the best response by the nurse is:

• A. "Elder adults are psychologically and physically capable of engaging in sexual activity regardless of age-related changes."?
• B. "If you haven't been sexually active throughout your life, you will not be able to participate in sexual activity in old age."?
• C. "When intercourse isn't possible, many of your sexual needs can be met through intimacy and touch."?
• D. "You might find it takes longer for you to achieve an erection, but you can maintain it for a longer time."?

Correct answer: A

Rationale: The best response for the nurse when an elder client asks about capability for sexual activity in old age is to provide reassurance and open communication. Choice A is the correct answer as it acknowledges that elder adults can engage in sexual activity both physically and psychologically despite age-related changes. This response encourages further discussion and addresses the client's concerns. Choices B, C, and D contain some truths but are not the most therapeutic responses. Choice B implies that past sexual activity is a prerequisite for sexual activity in old age, which is not entirely accurate as intimacy can be experienced in various ways. Choice C, while true about alternative ways to meet sexual needs, does not directly address the client's question about sexual activity. Choice D focuses on the physiological aspect of sexual function, which is important but not the most appropriate initial response to the client's query.

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