Nursing Elites

1. Which contraindication should be assessed for prior to administering an immunization to a child?

• A. Mild cold symptoms
• B. Chronic asthma
• C. Depressed immune system
• D. Allergy to eggs

Correct answer: C

Rationale: Before administering immunizations to children, it is crucial to assess for contraindications. A depressed immune system, such as that seen in conditions like HIV or due to chemotherapy, is a significant contraindication. Immunizations may not be safe or effective in children with compromised immune systems. Mild cold symptoms, although not ideal, are not a contraindication for routine immunizations. Chronic asthma, while a consideration, is not a direct contraindication for routine immunizations. Allergy to eggs is a contraindication for specific vaccines, such as influenza vaccine that is grown in eggs, but it is not a contraindication for all immunizations.

2. In which situation would the nurse use bimanual palpation technique?

• A. Palpating the thorax of an infant
• B. Palpating the kidneys and uterus
• C. Assessing pulsations and vibrations
• D. Assessing the presence of tenderness and pain

Correct answer: B

Rationale: Bimanual palpation involves using both hands to envelop or capture specific body parts or organs like the kidneys, uterus, or adnexa. This technique is particularly useful for assessing the size, shape, consistency, and mobility of deep organs like the kidneys and uterus. Palpating the thorax of an infant (Choice A) is usually done with a different technique like gentle, single-handed palpation. Assessing pulsations and vibrations (Choice C) and assessing tenderness and pain (Choice D) typically do not require the use of bimanual palpation, making Choices A, C, and D incorrect.

3. A patient's Foley catheter has been discontinued. You will dispose of this patient equipment by doing which of the following?

• A. Wearing gloves and then placing this equipment in the regular trash can after it is placed in a paper bag.
• B. Simply placing this equipment in the regular trash can after it is placed in a paper bag.
• C. Wearing gloves and then placing this equipment into a special 'hazardous waste' container.
• D. Simply placing this equipment in the 'hazardous waste' container after it is placed in a paper bag.

Correct answer: C

Rationale: When disposing of used patient equipment, such as a Foley catheter, that has come in contact with bodily fluids, it is considered hazardous waste. The correct procedure involves wearing gloves and placing the Foley bag and tubing into a special 'hazardous waste' container. This container is marked as 'Hazardous' and is typically red to indicate the potential danger of its contents. Placing the equipment in a regular trash can, even if placed in a paper bag, is not appropriate as it does not meet the standards for disposing of hazardous waste. Therefore, options A and B are incorrect. Similarly, simply placing the equipment in a 'hazardous waste' container after it is placed in a paper bag is also incorrect as direct disposal into the designated container while wearing gloves is the proper protocol, making option D incorrect.

4. What type of blood pressure measurement error is most likely to occur if the nurse does not check for the presence of an auscultatory gap?

• A. Diastolic blood pressure may not be heard.
• B. Diastolic blood pressure may be falsely low.
• C. Systolic blood pressure may be falsely low.
• D. Systolic blood pressure may be falsely high.

Correct answer: C

Rationale: If an auscultatory gap is undetected, a falsely low systolic reading may occur. This gap can lead to an underestimation of the systolic blood pressure, causing potential misinterpretation of the patient's condition. The diastolic blood pressure may not be heard due to the gap, but the critical issue in this scenario is the risk of underestimating systolic blood pressure, which can impact clinical decision-making. Choices B, C, and D are incorrect because the key concern in this context is the potential for a falsely low systolic blood pressure reading when an auscultatory gap is not assessed.

5. The nurse is preparing to perform a physical assessment. The correct action by the nurse is reflected by which statement?

• A. Performs the examination from both sides of the bed.
• B. Examines tender or painful areas last to help relieve the patient's anxiety.
• C. Follows a flexible examination sequence, considering the patient's age and condition.
• D. Organizes the assessment to ensure that the patient does not change positions too often.

Correct answer: D

Rationale: The nurse should organize the assessment to minimize the patient's need to change positions frequently, ensuring efficiency and comfort. It is essential to perform the examination from both sides of the bed to facilitate a comprehensive assessment. Examining tender or painful areas last can help reduce patient discomfort and anxiety. The examination sequence should be flexible, taking into account the patient's age, condition, and specific needs. This approach allows for a tailored and patient-centered assessment, optimizing the quality of care provided.

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