Nursing Elites

1. A healthcare professional is considering which patient to admit to the same room as a patient who had a liver transplant 3 weeks ago and is now hospitalized with acute rejection. Which patient would be the best choice?

• A. Patient who is receiving chemotherapy for liver cancer
• B. Patient who is receiving chemotherapy for lung cancer
• C. Patient who has a wound infection after cholecystectomy
• D. Patient who requires pain management for chronic pancreatitis

Correct answer: D

Rationale: The patient with chronic pancreatitis is the best choice to admit to the same room as a patient who had a liver transplant and is experiencing acute rejection. This is because the patient with chronic pancreatitis does not pose an infection risk to the immunosuppressed patient who had a liver transplant. On the other hand, patients receiving chemotherapy for cancer or those with wound infections are at risk for infections, which could endanger the immunosuppressed patient with acute rejection.

2. For a patient with cirrhosis, which of the following nursing actions can the registered nurse (RN) delegate to unlicensed assistive personnel (UAP)?

• A. Assessing the patient for jaundice
• B. Providing oral hygiene after a meal
• C. Palpating the abdomen for distention
• D. Assisting the patient to choose the diet

Correct answer: B

Rationale: Providing oral hygiene after a meal is an appropriate task to delegate to unlicensed assistive personnel (UAP) as it falls within their scope of practice. UAP can assist with basic personal care activities like oral hygiene. Assessing the patient for jaundice and palpating the abdomen for distention involve making clinical assessments that require a higher level of education and training, typically performed by licensed practical/vocational nurses (LPNs/LVNs) or registered nurses (RNs). Assisting the patient to choose the diet also requires specialized knowledge and would be more appropriate for a nurse to address, considering the complexity of dietary requirements in cirrhosis.

3. The body system that functions to maintain fluid balance, support immunity, and contains the spleen is the:

• A. Lymphatic System
• B. Digestive System
• C. Urinary System
• D. Respiratory System

Correct answer: A

Rationale: The Lymphatic System is responsible for maintaining fluid balance and supporting immunity. It contains organs like the spleen, tonsils, thymus, lymph nodes, and lymph vessels. The spleen, a part of the lymphatic system, plays a crucial role in filtering blood and storing blood cells. The Digestive System is primarily involved in the breakdown and absorption of nutrients, not fluid balance or immunity. The Urinary System is responsible for filtering waste products from the blood and regulating fluid balance, but it does not support immunity or contain the spleen. The Respiratory System is focused on gas exchange and oxygenating the blood, not fluid balance or immunity.

4. Which of the following is a disadvantage of using a dry heat application?

• A. Dry heat is more likely to cause burns than moist heat
• B. Dry heat does not penetrate deeply into the tissues
• C. Dry heat causes the skin to dry out more quickly
• D. Dry heat can quickly cause skin breakdown

Correct answer: C

Rationale: The correct answer is that dry heat causes the skin to dry out more quickly. When comparing dry and moist heat applications, dry heat is less likely to cause burns and skin breakdown. However, one of the disadvantages of dry heat is that it does not penetrate deeply into the tissues and may lead to faster drying out of the skin. This can have negative effects on skin integrity and overall comfort during therapy. Choice A is incorrect because dry heat is less likely to cause burns than moist heat. Choice B is incorrect as dry heat may not penetrate deeply into tissues. Choice D is incorrect as dry heat is less likely to cause skin breakdown compared to moist heat.

5. A patient's nursing diagnosis is Insomnia. The desired outcome is: 'Patient will sleep for a minimum of 5 hours nightly by October 31.' On November 1, a review of the sleep data shows the patient sleeps an average of 4 hours nightly and takes a 2-hour afternoon nap. Which evaluation should be documented?

• A. Consistently demonstrated
• B. Often demonstrated
• C. Sometimes demonstrated
• D. Never demonstrated

Correct answer: D

Rationale: The correct answer is 'Never demonstrated.' Despite the patient sleeping a total of 6 hours daily, it is not achieved in one uninterrupted session at night as per the desired outcome. The patient's habit of taking a 2-hour afternoon nap also affects the evaluation. Therefore, the outcome should be evaluated as 'Never demonstrated.' Choice A, 'Consistently demonstrated,' is incorrect because the desired outcome of sleeping for a minimum of 5 hours nightly in one session is not met. Choice B, 'Often demonstrated,' is incorrect as the patient's sleep pattern does not consistently align with the desired outcome. Choice C, 'Sometimes demonstrated,' is also incorrect as the patient's sleep pattern does not meet the specific criteria set in the desired outcome.

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