Nursing Elites

1. What is an attack using microorganisms such as bacteria or viral agents with the intent to harm others called?

• A. Assimilation
• B. Defense intervention
• C. Bioterrorism
• D. Environmental remediation

Correct answer: C

Rationale: Bioterrorism is the act of using harmful agents like bacteria or viruses with the intention to harm others. In the context of healthcare, nurses may be involved in disaster response if bioterrorism weapons affect the community. Choice A, assimilation, refers to the process of absorbing and integrating information or ideas. Choice B, defense intervention, does not specifically relate to the intentional use of microorganisms to harm others. Choice D, environmental remediation, involves the process of cleaning up pollution or contamination in the environment, which is unrelated to the deliberate use of pathogens for harmful purposes.

2. Your patient ate an 8-ounce cup of Italian ice. How much will you record on the patient's Intake and Output form in terms of this patient's fluid intake?

• A. 240 cc
• B. 120 cc
• C. 8 cc
• D. 0 cc because Italian ice is not a fluid

Correct answer: A

Rationale: The correct answer is 240 cc. Italian ice is considered a fluid, so you would record the intake of 240 cc. Choice B (120 cc) and Choice C (8 cc) are incorrect as they do not reflect the correct amount of fluid intake from an 8-ounce cup of Italian ice. Choice D (0 cc) is incorrect because Italian ice does count as a fluid intake and should be recorded as such.

3. During the general survey, what action is a component of the assessment?

• A. Observing the patient's body stature and nutritional status
• B. Interpreting the subjective information reported by the patient
• C. Measuring the patient's temperature, pulse, respirations, and blood pressure
• D. Observing specific body systems during the physical assessment

Correct answer: A

Rationale: During the general survey, the nurse assesses the patient's overall appearance, body structure, mobility, and behavior, which includes observing body stature and nutritional status. Interpreting subjective information reported by the patient is part of the subjective data collection process and not the general survey. Measuring vital signs like temperature, pulse, respirations, and blood pressure is part of a focused physical examination, not the general survey. Additionally, observing specific body systems while performing a physical assessment is more specific and focused than the general survey.

4. A healthcare professional is asked to draw blood in the antecubital (AC) space. Which of the following veins are found in the AC?

• A. Cephalic
• B. Median cubital
• C. Basilic
• D. All of the above

Correct answer: D

Rationale: The correct answer is 'All of the above.' All three of these veins - the cephalic, median cubital, and basilic veins - are located in the antecubital space, which is the area in front of the elbow on the arm. The cephalic vein runs along the outer side of the arm, the basilic vein runs along the inner side of the arm, and the median cubital vein is a connecting vein between the cephalic and basilic veins. Therefore, all three veins can be accessed when drawing blood from the antecubital space. Choices A, B, and C are incorrect because each of these veins individually can be found in the antecubital space.

5. A client is preparing to administer an enema to a 64-year-old client. Which of the following actions of the nurse is most appropriate?

• A. Assist the client to lie in the semi-Fowler position
• B. Apply lubricating jelly to the tip of the catheter before insertion
• C. Instill a total of 30cc of fluid into the client's rectum
• D. Ask the client to hold the solution in for 30 seconds

Correct answer: B

Rationale: When administering an enema to a client, the nurse should place the client in the Sims' position for easy access. The correct action is to apply lubricating jelly to the tip of the catheter before insertion to facilitate a smoother procedure. It is essential to instill a maximum of 750 to 1000 cc of fluid for an adult client, not just 30cc. Following administration, the nurse should ask the client to hold the solution for at least 5 minutes to allow for the desired effect of the enema. Therefore, choice B is the most appropriate action, as choices A, C, and D are incorrect due to inaccuracies in positioning, enema volume, and retention time.

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