Nursing Elites

1. Based on the principle of asepsis, which situation should the nurse consider to be sterile?

• A. A one-inch border around the edges of a sterile field set up in the operating room
• B. A sterile glove that the nurse thinks might have touched her hair
• C. A wrapped, unopened sterile 4x4 gauze pad placed on a damp tabletop
• D. An open sterile Foley catheter kit set up on a table at the nurse's waist level

Correct answer: D

Rationale: The correct answer is D because an open sterile Foley catheter kit set up at waist level is considered sterile if it has not been contaminated. Choice A is incorrect because the one-inch border around a sterile field is considered non-sterile. Choice B is incorrect because a sterile glove that might have touched the nurse's hair is likely contaminated. Choice C is incorrect because a wrapped, unopened sterile gauze pad placed on a damp tabletop may have become contaminated.

2. A homeless male client with a history of alcohol abuse had a CVA 10 years ago that resulted in left hemiparesis. Today he is brought to the clinic reporting pain in his left leg. He is afebrile, has 4+ pitting edema in the lower left leg, and has minimal swelling of the right leg. Which action should the PN implement first?

• A. Obtain a blood alcohol test
• B. Inspect legs for infection or trauma
• C. Complete a mental status exam
• D. Inquire about dietary salt intake

Correct answer: B

Rationale: Inspecting the legs for infection or trauma is the priority to assess the cause of the pain and edema, which could indicate deep vein thrombosis or cellulitis. Checking for signs of infection or trauma is crucial in this scenario to rule out potentially serious conditions. Obtaining a blood alcohol test, completing a mental status exam, or inquiring about dietary salt intake can be considered after addressing the immediate concern of identifying any infection or trauma in the leg.

3. When reinforcing diet teaching for a client diagnosed with hypokalemia, which foods should the PN encourage the client to eat? Select All That Apply

• A. Orange juice, oranges, bananas
• B. All are applicable
• C. Collard greens, kale, turnips
• D. Soybeans, lima beans, spinach

Correct answer: B

Rationale: The correct answer is B: All are applicable. Foods rich in potassium, such as orange juice, oranges, bananas, collard greens, kale, soybeans, lima beans, and spinach, are essential for managing hypokalemia. These options provide a significant source of potassium, which helps in maintaining normal heart and muscle function. Choice A is incorrect because it does not include all the appropriate potassium-rich foods. Choice C is incorrect as it only mentions vegetables rich in potassium, missing out on other essential sources like fruits and beans. Choice D is incorrect as it lacks key potassium-rich foods like oranges and bananas.

4. What dietary considerations must the nurse keep in mind for a patient who is an Orthodox Jew?

• A. They can eat any food unless it is Yom Kippur
• B. They cannot mix meat and dairy
• C. They cannot eat meat on Ash Wednesday
• D. They are vegetarian

Correct answer: B

Rationale: Orthodox Jews follow dietary laws (Kashrut) that prohibit mixing meat and dairy products in the same meal. This restriction is known as 'not mixing milk and meat.' Therefore, choice B is the correct answer. Choices A, C, and D are incorrect because being an Orthodox Jew does not mean they can eat any food unless it is Yom Kippur, avoid meat on Ash Wednesday, or are necessarily vegetarian.

5. The nurse assigns a UAP to assist with the personal care of a client experiencing an acute exacerbation of multiple sclerosis. Which instruction should the nurse provide the UAP?

• A. Assist the client with a hot bath
• B. Encourage self-care but allow rest periods
• C. Face the client directly when speaking
• D. Keep the head of the bed elevated at all times

Correct answer: B

Rationale: The correct instruction for the UAP to provide when assisting a client experiencing an acute exacerbation of multiple sclerosis is to encourage self-care but allow rest periods. Clients with multiple sclerosis often experience fatigue, so promoting self-care activities while ensuring they have adequate rest periods is crucial for symptom management and maintaining independence. Choice A is incorrect as hot baths can potentially exacerbate symptoms in clients with multiple sclerosis. Choice C is unrelated to the client's care needs during an acute exacerbation of multiple sclerosis. Choice D is not a priority instruction in this situation and may not directly impact the client's immediate care needs.

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