Nursing Elites

1. 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.

2. When taking blood pressures on a variety of people at a health fair, what should the nurse keep in mind?

• A. After menopause, blood pressure readings in women are usually higher than those taken in men.
• B. The blood pressure of an African-American adult is usually higher than that of a non-Hispanic White adult of the same age.
• C. Blood pressure measurements in people who are overweight are usually higher than those of people who are at a normal weight.
• D. A teenager's blood pressure reading may be lower than that of an adult.

Correct answer: B

Rationale: When assessing blood pressures, it is important to consider that the blood pressure of African-American adults is typically higher than that of non-Hispanic White adults of the same age. This is significant as Black individuals in the United States have a higher prevalence of hypertension compared to other groups. Blood pressure readings in women are generally higher than in men after menopause. Additionally, blood pressure measurements in overweight individuals are typically higher than those in individuals of normal weight. While teenagers may have lower blood pressure readings than adults, it is crucial to recognize the trend of a gradual rise in blood pressure throughout childhood and into adulthood. Therefore, the correct choice is B. Choices A, C, and D are incorrect as they do not reflect the typical blood pressure differences observed in various populations.

3. When performing a physical examination, safety must be considered to protect the examiner and the patient against the spread of infection. Which of these statements describes the most appropriate action the nurse would take when performing a physical examination?

• A. Washing one's hands after removing gloves is necessary, even if the gloves are still intact
• B. Hands are washed before and after every physical patient encounter
• C. Hands are washed before the examination of each body system to prevent the spread of bacteria from one part of the body to another
• D. Gloves are worn throughout the entire examination to demonstrate concern regarding the spread of infectious diseases

Correct answer: B

Rationale: The most appropriate action for the nurse to take when performing a physical examination is to wash their hands before and after every physical patient encounter. This practice helps prevent the spread of infection. Hands should also be washed after contact with blood, body fluids, secretions, and excretions, and after contact with any equipment contaminated with body fluids. It is crucial to wash hands after removing gloves, even if the gloves appear intact. Choice A is incorrect because washing hands after removing gloves is necessary to ensure thorough hygiene. Choice C is incorrect because hands should be washed before and after every patient encounter, not just before examining each body system. Choice D is incorrect because gloves should be worn when there is potential contact with body fluids, but they do not need to be worn throughout the entire examination.

4. A client is preparing to irrigate a colostomy. Which of the following situations is a contraindication for this type of irrigation?

• A. The client has an incontinent ostomy
• B. The client has an irregular bowel routine
• C. The client has diverticulitis
• D. The colostomy bag contains fecal material

Correct answer: C

Rationale: When a client with a colostomy is preparing for irrigation, it is essential to consider contraindications that could pose risks or worsen the client's condition. Diverticulitis is a contraindication for colostomy irrigation because the inflamed diverticula could be further irritated by the flushing action during irrigation, potentially leading to complications. An incontinent ostomy, irregular bowel routine, or presence of fecal material in the colostomy bag are not specific contraindications for irrigation and can be managed through appropriate techniques and interventions.

5. When performing a physical assessment, what technique should the nurse always perform first?

• A. Palpation
• B. Inspection
• C. Percussion
• D. Auscultation

Correct answer: B

Rationale: During a physical assessment, the nurse should always begin with inspection. The sequence of techniques for physical examination is inspection, palpation, percussion, and auscultation. These skills are performed in a specific order, except for the abdominal assessment where auscultation precedes palpation and percussion. Inspection allows the nurse to observe and gather initial information without direct contact. It is a crucial step that provides valuable insights before proceeding to palpation, percussion, and auscultation. Therefore, choice B, 'Inspection,' is the correct answer. Choices A, C, and D are incorrect because they should follow inspection in the sequence of a comprehensive physical assessment.

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