Nursing Elites

1. When placing an IV line in a patient with active TB and HIV, which safety equipment should the nurse wear?

• A. Sterile gloves, mask, and goggles
• B. Surgical cap, gloves, mask, and proper shoewear
• C. Double gloves, gown, and mask
• D. Goggles, mask, gloves, and gown

Correct answer: D

Rationale: When dealing with a patient with active TB and HIV, the nurse should wear goggles, a mask, gloves, and a gown to protect themselves from potential exposure to infectious agents through respiratory secretions or blood. Surgical cap and proper shoewear are not specifically required for this procedure, making option B incorrect. Double gloving is not necessary in this scenario, hence option C is incorrect. Therefore, the correct choice is D as it includes all the essential protective equipment for this situation.

2. A 32-year-old male with a complaint of dizziness has an order for Morphine via IV. What should the nurse do first?

• A. Check the patient's chest x-ray results.
• B. Retake vitals including blood pressure.
• C. Perform a neurological screening on the patient.
• D. Request the physician on-call to assess the patient.

Correct answer: B

Rationale: The correct first action for the nurse to take in this situation is to retake the patient's vitals, including blood pressure. Dizziness can be a sign of hypotension, which may be a contraindication for administering Morphine. Checking the chest x-ray results (Choice A) would not be the priority in this case as addressing the dizziness is more urgent. Performing a neurological screening (Choice C) may be important but not the first step when a patient presents with dizziness and an order for Morphine. Requesting the physician to assess the patient (Choice D) should come after the initial assessment and vitals retake.

3. After an escharotomy of the forearm, what is the priority nursing assessment for the client who has returned to your unit?

• A. Infection
• B. Incision
• C. Pain
• D. Tissue perfusion

Correct answer: D

Rationale: The correct answer is "Tissue perfusion." After an escharotomy, the priority assessment is to ensure adequate tissue perfusion to the affected limb. Escharotomy is performed to relieve circulatory compromise by cutting through the eschar, so monitoring tissue perfusion is crucial to assess the effectiveness of the procedure and prevent complications. Assessing for infection is important but comes after ensuring adequate tissue perfusion. Checking the incision is necessary but assessing tissue perfusion takes precedence. Pain assessment is important but not the priority compared to assessing tissue perfusion to prevent ischemic complications.

4. The client is scheduled for surgical repair of a detached retina. What is the most likely preoperative nursing diagnosis for this client?

• A. Anxiety related to loss of vision and potential failure to regain vision.
• B. Deficient knowledge (preoperative and postoperative activities) related to lack of information.
• C. Acute pain related to tissue injury and decreased circulation to the eye.
• D. Risk for infection related to the eye injury.

Correct answer: A

Rationale: The correct preoperative nursing diagnosis for a client scheduled for surgical repair of a detached retina is 'Anxiety related to loss of vision and potential failure to regain vision.' A client facing the threat of permanent blindness due to a detached retina is likely to experience anxiety. Addressing this anxiety is crucial before providing education, as severe anxiety can hinder the client's ability to absorb new information. The nurse should offer emotional support, encourage the client to express concerns, and clarify any misconceptions. Acute pain is not a typical symptom of a detached retina, and the risk of infection preoperatively is minimal, making choices C and D less relevant in this scenario.

5. Which of the following procedures describes an opening between the colon and abdominal wall?

• A. ileostomy
• B. jejunostomy
• C. colostomy
• D. cecostomy

Correct answer: C

Rationale: A colostomy is an opening between the colon and abdominal wall. An ileostomy is an opening between the ileum and abdominal wall, not the colon. Jejunostomy is an opening between the jejunum and abdominal wall, and cecostomy is an opening into the cecum. The term 'colostomy' specifically refers to the surgical procedure where a part of the colon is brought through the abdominal wall to create a stoma, allowing feces to leave the body. Therefore, the correct answer is colostomy as it accurately describes the opening between the colon and the abdominal wall, distinct from the other options.

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