Nursing Elites

1. All of the following statements are true about donning sterile gloves except:

• A. The first glove should be picked up by grasping the inside of the cuff.
• B. The second glove should be picked up by inserting the gloved fingers under the cuff outside the glove.
• C. The gloves should be adjusted by sliding the gloved fingers under the sterile cuff and pulling the glove over the wrist.
• D. The inside of the glove is considered sterile.

Correct answer: D

Rationale: When donning sterile gloves, it is essential to maintain sterility. The correct way to don sterile gloves includes grasping the outside of the cuff to put on the first glove and inserting the gloved fingers under the cuff outside the glove to put on the second glove. Adjustments should be made by sliding the fingers under the sterile cuff. It is crucial to remember that once the inside of the glove is touched during the donning process, it is no longer considered sterile.

2. A healthcare provider is caring for an adolescent who has sickle-cell anemia. Which of the following manifestations indicates acute chest syndrome and should be immediately reported to the provider?

• A. Substernal retractions
• B. Hematuria
• C. Temperature 37.9�C (100.2�F)
• D. Sneezing

Correct answer: A

Rationale: Substernal retractions are a concerning sign of respiratory distress and can indicate acute chest syndrome, a severe complication of sickle-cell anemia. It results from vaso-occlusion in the pulmonary vasculature, leading to impaired oxygenation. Prompt reporting of this symptom is crucial for early intervention to prevent further complications. Hematuria, a high temperature, and sneezing are not specific manifestations of acute chest syndrome and would not warrant immediate notification to the provider in this context.

3. A healthcare professional in the emergency department is assessing a client who has a suspected flail chest. Which of the following findings should the professional not expect?

• A. Bradycardia
• B. Cyanosis
• C. Hypotension
• D. Dyspnea

Correct answer: A

Rationale: Bradycardia is not typically associated with a flail chest. Flail chest is characterized by paradoxical chest wall movement, respiratory distress, and hypoxia, but it does not usually cause bradycardia. The other options, such as cyanosis (bluish discoloration of the skin due to poor oxygenation), hypotension (low blood pressure), and dyspnea (difficulty breathing), are commonly seen in patients with flail chest due to the underlying respiratory compromise.

4. A nurse is providing teaching about gastrostomy tube feedings to the parents of a school-age child. Which of the following instructions should the nurse give?

• A. Administer the feeding over 30 minutes
• B. Place the child in a supine position after the feeding
• C. Change the feeding bag and tubing every 3 days
• D. Warm the formula in a warm water bath before administration

Correct answer: B

Rationale: Administering the feeding over 30 minutes helps prevent complications such as aspiration. Placing the child in an upright position after the feeding is recommended to reduce the risk of aspiration. It is essential to change the feeding bag and tubing every 3 days to maintain asepsis and prevent infections. Warming the formula in a warm water bath is the correct method as using a microwave can create hot spots that may burn the child's mouth or throat.

5. What is the most appropriate nursing order for a patient who develops dyspnea and shortness of breath?

• A. Maintain the patient on strict bed rest at all times
• B. Maintain the patient in an orthopneic position as needed
• C. Administer high-flow oxygen immediately
• D. Encourage the patient to engage in vigorous physical activity

Correct answer: B

Rationale: Maintaining the patient in an orthopneic position as needed is the most appropriate nursing order for a patient experiencing dyspnea and shortness of breath. This position helps to optimize lung expansion, improve oxygenation, and alleviate breathing difficulties. It is a strategic intervention to enhance respiratory function in patients with respiratory distress. Choice A is incorrect because strict bed rest may not address the underlying respiratory issue effectively. Choice C is premature as administering high-flow oxygen should be based on a comprehensive assessment. Choice D is inappropriate as encouraging vigorous physical activity can exacerbate breathing problems in a patient experiencing dyspnea.

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