Nursing Elites

1. The nurse should wash from the ________________________ when washing a patient's eye area.

• A. outer canthus to the inner canthus
• B. inner canthus to the outer canthus
• C. internal nares to the external nares
• D. external nares to the internal nares

Correct answer: B

Rationale: When washing a patient's eye area, it is important to start from the inner canthus (closest to the nose) and move towards the outer canthus. This direction prevents any contaminants or debris from the outer area of the eye from moving towards the inner, more sensitive area. Choices C and D are incorrect as they pertain to the nasal passages (nares), which are not relevant when washing the eye area.

2. The nurse is developing a plan of care for an infant after surgical intervention for imperforate anus. The nurse should include in the plan that which position is the most appropriate one for the infant in the postoperative period?

• A. Prone position
• B. Supine with no head elevation
• C. Side-lying with the legs extended
• D. Supine with the head elevated 45 degrees

Correct answer: A

Rationale: The most appropriate position for an infant after surgical intervention for imperforate anus is the prone position. Placing the infant in a prone position helps keep the hips elevated, reducing edema and pressure on the surgical site. This position promotes optimal healing and comfort for the infant. Option B, supine with no head elevation, does not provide the necessary elevation to reduce pressure on the surgical site. Option C, side-lying with the legs extended, does not offer the same benefits as the prone position in terms of reducing pressure on the surgical site. Option D, supine with the head elevated 45 degrees, does not specifically address the need for hip elevation to prevent pressure on the surgical site. Therefore, the correct choice is the prone position for this postoperative care scenario.

3. What is the minimum amount of personal protective equipment for a nurse when working with a newborn immediately after a high-risk delivery in a client's room?

• A. Sterile gown, gloves
• B. Mask, gown, shoe covers
• C. Gloves
• D. Hat, mask, gloves, gown, shoe covers

Correct answer: C

Rationale: The correct answer is gloves. When attending a high-risk delivery and handling a newborn immediately after birth, the minimum personal protective equipment required for a nurse includes gloves. This is essential to protect the nurse from potential exposure to the mother's blood or body fluids that may be present on the newborn's skin. Choices A, B, and D include additional protective equipment that is not necessary for this specific scenario. Wearing gloves is crucial for infection control and to prevent the transmission of pathogens.

4. The nurse is assessing an 80-year-old male patient. Which assessment finding would be considered normal?

• A. Decrease in body weight from his younger years
• B. Decrease in deposits of fat in the cheeks and forearms
• C. Presence of kyphosis and flexion in bilateral knees and hips
• D. Change in overall body proportion, including a longer trunk and shorter extremities

Correct answer: C

Rationale: In an 80-year-old male patient, the presence of kyphosis (rounded upper back) and flexion in bilateral knees and hips are considered normal age-related changes. These postural changes are commonly seen in older adults due to structural changes in the spine and joints. Option A is incorrect as aging individuals typically experience a decrease in body weight, not an increase. Option B is also incorrect as there is usually a decrease in subcutaneous fat from the face and periphery, rather than an increase in fat deposits in specific areas. Option D is incorrect because the change in overall body proportion with aging usually involves a shorter trunk and relatively longer extremities, not the other way around. This is because long bones do not shorten with age, leading to this characteristic change in body proportions.

5. When performing a physical examination, safety must be considered to protect the examiner and the patient against the spread of infection. Which of these statements describes the most appropriate action the nurse would take when performing a physical examination?

• A. Washing one's hands after removing gloves is necessary, even if the gloves are still intact
• B. Hands are washed before and after every physical patient encounter
• C. Hands are washed before the examination of each body system to prevent the spread of bacteria from one part of the body to another
• D. Gloves are worn throughout the entire examination to demonstrate concern regarding the spread of infectious diseases

Correct answer: B

Rationale: The most appropriate action for the nurse to take when performing a physical examination is to wash their hands before and after every physical patient encounter. This practice helps prevent the spread of infection. Hands should also be washed after contact with blood, body fluids, secretions, and excretions, and after contact with any equipment contaminated with body fluids. It is crucial to wash hands after removing gloves, even if the gloves appear intact. Choice A is incorrect because washing hands after removing gloves is necessary to ensure thorough hygiene. Choice C is incorrect because hands should be washed before and after every patient encounter, not just before examining each body system. Choice D is incorrect because gloves should be worn when there is potential contact with body fluids, but they do not need to be worn throughout the entire examination.

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