Nursing Elites

1. When cleansing the genital area during perineal care, the nurse should _____________.

• A. cleanse the penis with a circular motion starting from the base and moving toward the tip.
• B. replace the foreskin after it has been pushed back to cleanse an uncircumcised penis.
• C. cleanse the rectal area first and then clean the patient's genital area.
• D. use the same area on the washcloth for each washing and rinsing stroke for a female resident.

Correct answer: B

Rationale: During perineal care, when cleansing the genital area of an uncircumcised male patient, it is crucial to retract the foreskin to clean the area underneath. This helps in the removal of smegma, a substance that can accumulate and lead to bacterial growth and infection if not cleaned properly. The foreskin should then be replaced back to its original position after cleaning to ensure proper hygiene and prevent any potential complications. Choices A, C, and D are incorrect because they do not address the specific care required for an uncircumcised penis, which involves retracting and replacing the foreskin.

2. The rehabilitation nurse wishes to make the following entry into a client's plan of care: 'Client will reestablish a pattern of daily bowel movements without straining within two months.' The nurse would write this statement under which section of the plan of care?

• A. Nursing diagnosis/problem list
• B. Nursing orders
• C. Short-term goals
• D. Long-term goals

Correct answer: D

Rationale: The correct answer is 'Long-term goals.' Long-term goals are designed to describe changes in client behavior expected over a time frame greater than one week. In this case, the goal of reestablishing a pattern of daily bowel movements without straining within two months falls under a long-term goal. Long-term goals are aimed at restoring normal functioning in a problem area and are beneficial for healthcare workers caring for the client across different settings. Choices A, B, and C are incorrect because nursing diagnosis/problem list, nursing orders, and short-term goals do not encompass the desired timeframe or level of expected change in this scenario.

3. When performing an EKG, the patient starts to laugh out of feelings of anxiety. What would you expect the EKG to show? (Choose the BEST answer.)

• A. Increased pulse rate, normal EKG
• B. Decreased pulse rate, abnormal EKG
• C. Tachycardia, poor EKG graph
• D. Bradycardia, poor EKG graph

Correct answer: C

Rationale: When a patient laughs due to anxiety during an EKG, it is likely to cause tachycardia, which is a rapid heart rate. This increased heart rate can lead to poor EKG graph quality as the electrical signals from large moving muscles can interfere with data collection from the chest leads. Therefore, in this scenario, the EKG is expected to show tachycardia with poor graph quality. Choices A, B, and D are incorrect because a patient laughing out of anxiety is more likely to result in an increased pulse rate (tachycardia) rather than a decreased pulse rate (bradycardia) or a normal EKG.

4. Nursing care plans contain which of the following?

• A. nursing diagnoses
• B. medical diagnoses.
• C. MD orders.
• D. intake and output forms

Correct answer: A

Rationale: Nursing care plans are legal documents that contain nursing diagnoses, such as an "Alteration of respiratory function". They also contain patient goals and nursing interventions.

5. The nurse is reviewing percussion techniques with a new graduate nurse. Which action performed by the graduate nurse while percussing requires the nurse to intervene?

• A. Percussing twice over each area
• B. Striking with the fingertip, not the finger pad
• C. Using the wrist to make the strikes, not the arm
• D. Quickly lifting the striking finger after each stroke

Correct answer: A

Rationale: The correct answer is to percuss twice over each area, not once. This technique helps ensure a more accurate assessment. Striking with the fingertip instead of the finger pad is correct because the tip of the finger produces clearer sounds. Using the wrist to make the strikes instead of the arm is appropriate as it allows for more controlled and precise percussion. Quickly lifting the striking finger after each stroke is also correct to prevent damping off vibrations. Therefore, percussing once over each area (Choice A) is incorrect as it does not follow the standard percussion technique.

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