Nursing Elites

1. Which of the following organs would be described as being located retroperitoneally?

• A. Kidneys
• B. Thymus
• C. Small Intestines
• D. Spleen

Correct answer: A

Rationale: The term 'retroperitoneal' refers to organs positioned behind the peritoneum. The kidneys are retroperitoneal organs, located outside the peritoneal cavity, against the posterior abdominal wall. This positioning provides them with additional protection from external forces due to the surrounding structures. The thymus, small intestines, and spleen are not retroperitoneal organs. The thymus is located in the mediastinum, the small intestines are intraperitoneal, and the spleen is intraperitoneal and located in the left upper quadrant of the abdomen.

2. Which of the following diseases would require the nurse to wear an N95 respirator as part of personal protective equipment?

• A. Human immunodeficiency virus
• B. Clostridium difficile enterocolitis
• C. Vancomycin-resistant enterococcus
• D. Measles

Correct answer: D

Rationale: Infections that require airborne precautions necessitate the use of an N95 respirator, a type of mask that filters particles that are 5 micrograms or smaller. Illnesses that require airborne precautions include Measles, Varicella, Severe Acute Respiratory Syndrome (SARS), and tuberculosis. Measles is a highly contagious airborne disease caused by a virus. It can spread through respiratory droplets when an infected person coughs or sneezes. Wearing an N95 respirator helps prevent the nurse from inhaling these infectious particles. Human immunodeficiency virus, Clostridium difficile enterocolitis, and Vancomycin-resistant enterococcus do not require the use of an N95 respirator as they are not transmitted through the air but have other modes of transmission.

3. When planning a cultural assessment, what component should the nurse include?

• A. Family history
• B. Chief complaint
• C. Medical history
• D. Health practices

Correct answer: D

Rationale: When conducting a cultural assessment, it is essential to include the patient's health practices. Health practices encompass the beliefs, values, and behaviors related to health and illness within a specific cultural context. These practices provide insight into how individuals perceive and manage their health. Family history, chief complaint, and medical history are crucial components of a patient's overall assessment but do not directly relate to a cultural assessment. Focusing on health practices allows the nurse to better understand the patient's cultural background and tailor care to meet their specific needs.

4. Which of the following actions is most appropriate for reducing the risk of infection during the post-operative period?

• A. Flush the central line with heparin at least every four hours
• B. Administer narcotic analgesics as needed
• C. Remove the urinary catheter as soon as the client is ambulatory
• D. Order a high-protein diet for the client

Correct answer: C

Rationale: The most appropriate action to reduce the risk of infection during the post-operative period is to remove the urinary catheter as soon as the client is ambulatory. Urinary catheters can serve as a source of bacteria, increasing the risk of infection in the bladder or urethra. By removing the catheter promptly once the client is mobile, the risk of infection can be minimized. Option A, flushing the central line with heparin, is not directly related to reducing urinary tract infections. Option B, administering narcotic analgesics as needed, is important for pain management but does not directly address infection prevention. Option D, ordering a high-protein diet, may be beneficial for wound healing but does not specifically target infection risk reduction in the post-operative period.

5. A client who complains of nausea and seems anxious is admitted to the nursing unit. The nurse should take which of the following actions regarding completion of the admission interview?

• A. Help the client to get settled and conduct the interview the next morning when the client is rested
• B. Conduct the interview immediately, directing the majority of the questions to the client
• C. Conduct the interview as soon as uninterrupted time is available to address the client's concerns
• D. Ask the charge nurse to interview the client while the admitting nurse calls the doctor for anti-nausea and anti-anxiety medication

Correct answer: C

Rationale: When dealing with a client who is experiencing nausea and anxiety, it is important to promptly conduct the admission interview to address their concerns. This allows for the collection of accurate data while attending to the client's immediate needs. Delaying the interview until the next morning (Choice A) may not be in the best interest of the client as timely assessment and intervention are essential. Directing questions to the client's spouse (Choice B) may not provide accurate information from the client themselves. Asking another nurse to conduct the interview while administering medications (Choice D) does not prioritize building a therapeutic relationship with the client, which is crucial in addressing their concerns and providing holistic care.

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