Nursing Elites

1. A PN is assigned to care for a newborn with a neural tube defect. Which dressing, if applied by the PN, would need no further intervention by the charge nurse?

• A. Telfa dressing with antibiotic ointment
• B. Moist sterile non-adherent dressing
• C. Dry sterile dressing that is occlusive
• D. Sterile occlusive pressure dressing

Correct answer: B

Rationale: The correct answer is B: Moist sterile non-adherent dressing. A moist sterile non-adherent dressing is suitable for covering a neural tube defect and would not require further intervention. This type of dressing helps prevent the dressing from sticking to the wound, minimizing trauma during dressing changes. Choice A, Telfa dressing with antibiotic ointment, is not ideal for a neural tube defect as the ointment may not be necessary and can complicate wound care. Choice C, dry sterile dressing that is occlusive, is not recommended for a neural tube defect as it may not provide the necessary environment for proper wound healing. Choice D, sterile occlusive pressure dressing, is excessive for a neural tube defect and may cause unnecessary pressure on the wound site.

2. A community health nurse is preparing a campaign about seasonal influenza. Which of the following plans should the nurse include as a secondary prevention?

• A. Screening groups of older adults in nursing care facilities for early influenza manifestations
• B. Promoting hand hygiene to prevent the spread of influenza
• C. Administering influenza vaccinations
• D. Educating about the importance of healthy lifestyle choices to prevent influenza

Correct answer: A

Rationale: The correct answer is A. Secondary prevention aims to detect and address health issues early. Screening older adults in nursing care facilities for early influenza manifestations is an example of secondary prevention by identifying cases at an early stage. Choice B, promoting hand hygiene, is a form of primary prevention that aims to prevent the occurrence of influenza. Choice C, administering influenza vaccinations, is a form of primary prevention as well, focusing on preventing the disease before it occurs. Choice D, educating about healthy lifestyle choices, is more related to health promotion and primary prevention rather than secondary prevention.

3. A healthcare professional is preparing to perform nasal tracheal suctioning for a client. Which of the following is an appropriate action for the healthcare professional to take?

• A. Hold the suction catheter with the non-dominant hand.
• B. Apply suctioning for 20 to 30 seconds.
• C. Place the catheter in a clean and dry location for later use.
• D. Use surgical asepsis when performing the procedure.

Correct answer: D

Rationale: Using surgical asepsis when performing nasal tracheal suctioning is crucial to prevent infection. Choice A is incorrect because the suction catheter should be held with the dominant hand to ensure better control and precision during the procedure. Choice B is incorrect as suctioning should be applied for no longer than 10 to 15 seconds to avoid trauma to the mucous membranes. Choice C is incorrect as the catheter should be disposed of properly after single-use to prevent cross-contamination and infection.

4. A client is scheduled for an appendectomy and has given informed consent. Which statement by the client should the nurse address first preoperatively?

• A. “I am afraid to walk if it hurts too much.”
• B. “I don’t understand why I need this surgery.”
• C. “I don’t want my family helping me after the surgery.”
• D. “I am afraid the scar will make me look disfigured.”

Correct answer: B

Rationale: The nurse should address the client's lack of understanding regarding the need for surgery first. Ensuring that the client comprehends the rationale for the procedure is essential for informed consent. Choices A, C, and D, while important, do not directly impact the client's understanding of the necessity of the surgery and can be addressed after clarifying the reason for the procedure.

5. A postoperative client will need to perform daily dressing changes after discharge. Which outcome statement best demonstrates the client's readiness to manage his wound care after discharge?

• A. Asks relevant questions regarding the dressing change.
• B. States he will be able to complete the wound care regimen.
• C. Demonstrates the wound care procedure correctly.
• D. Has all the necessary supplies for wound care.

Correct answer: C

Rationale: The correct answer is C. Demonstrating the wound care procedure correctly indicates the client's readiness to independently manage wound care. This action shows practical understanding and application of the necessary skills. Choice A, asking relevant questions, is important but does not directly demonstrate the ability to perform the procedure. Choice B, stating the ability to complete the regimen, is a good intention but does not confirm practical competence. Choice D, having necessary supplies, is essential but does not ensure the client's ability to execute proper wound care.

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