Nursing Elites

1. A patient's hygiene schedule of bathing and brushing teeth is largely influenced by family customs. For which age group is the nurse most likely providing care?

• A. Adolescent
• B. Preschooler
• C. Older adult
• D. Adult

Correct answer: B

Rationale: The correct answer is B: Preschooler. Family customs have a significant impact on hygiene practices during childhood, especially in the early years. Preschoolers are at an age where they are learning and forming habits, and family customs play a crucial role in establishing routines such as bathing and brushing teeth. Adolescents, older adults, and adults are more likely to have established their own hygiene routines that may not be as heavily influenced by family customs as in early childhood. Therefore, the nurse is most likely providing care to a preschooler in this scenario.

2. A home health nurse is teaching a new caregiver how to care for a client who has had a tracheostomy for 1 year. Which of the following instructions should the nurse include?

• A. Use tracheostomy covers when going outdoors.
• B. Maintain sterile technique when performing tracheostomy care.
• C. Do not remove the outer cannula for routine cleaning.
• D. Clean around the stoma with normal saline.

Correct answer: A

Rationale: The correct answer is to use tracheostomy covers when going outdoors. This instruction is important as it helps protect the airway from dust and other particles, reducing the risk of infection or irritation. Choice B is incorrect because maintaining sterile technique is crucial during tracheostomy care to prevent infections, but it is not the most pertinent instruction in this scenario. Choice C is incorrect as removing the outer cannula is not a routine cleaning procedure and should only be done by healthcare professionals when necessary. Choice D is incorrect because cleaning around the stoma with normal saline is not recommended as it can cause irritation to the skin and stoma site.

3. A healthcare professional is preparing to administer 0.9% sodium chloride (0.9% NaCl) 250 mL IV to infuse over 30 min. The drop factor of the manual IV tubing is 10 gtt/mL. How many gtt/min should the healthcare professional adjust the manual IV infusion to deliver? (Round the answer to the nearest whole number. Do not use a trailing zero.)

• A. 83 gtt/min
• B. 125 gtt/min
• C. 100 gtt/min
• D. 75 gtt/min

Correct answer: C

Rationale: To administer 250 mL over 30 min with a drop factor of 10 gtt/mL, the healthcare professional should adjust the IV infusion to deliver 100 gtt/min. The correct calculation is: (250 mL ÷ 30 min) x 10 gtt/mL = 100 gtt/min. This rate ensures the proper administration of the IV solution within the specified time frame. Choices A, B, and D are incorrect as they do not align with the accurate calculation based on the provided data.

4. A healthcare professional is supervising the logrolling of a patient. To which patient is the healthcare professional most likely providing care?

• A. A patient with neck surgery
• B. A patient with hypostatic pneumonia
• C. A patient with a total knee replacement
• D. A patient with a stage IV pressure ulcer

Correct answer: A

Rationale: Logrolling is a technique used to move a patient as a single unit to prevent twisting or bending of the spine. Patients who have undergone neck surgery require special care to ensure the spinal column remains in straight alignment to prevent further injury. Therefore, the correct answer is a patient with neck surgery. Choice B, a patient with hypostatic pneumonia, does not require logrolling, as it is a condition affecting the lungs, not the spine. Choice C, a patient with a total knee replacement, does not typically necessitate logrolling, as the procedure focuses on the knee joint, not the spine. Choice D, a patient with a stage IV pressure ulcer, requires wound care but does not necessarily involve logrolling unless the ulcer is located in a critical area that requires special handling.

5. A nurse is caring for a client who reports a pain level of 5 on a scale from 0-10. The client informs the nurse that pain medication is not an option for managing pain. Which of the following is an appropriate response by the nurse?

• A. I'm sure it will work if you just give it a chance.
• B. You may take any herbal remedies you bring from home.
• C. Why do you think pain medication is not going to help you?
• D. Would you like me to give you a back massage?

Correct answer: D

Rationale: In this scenario, the client has expressed that pain medication is not an option for managing pain. Offering alternative pain relief options like a back massage is appropriate because it respects the client's preferences and provides a non-pharmacological intervention to help alleviate pain. Choices A, B, and C are not as suitable: A may come across as dismissive of the client's decision, B may not be safe as herbal remedies can interact with medical treatments, and C focuses more on questioning the client's decision rather than providing immediate comfort.

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