Nursing Elites

1. A charge nurse is providing teaching to a newly licensed nurse on how to clean surfaces contaminated with blood. Which of the following agents should the nurse include in the teaching?

• A. Hydrogen peroxide
• B. Chlorhexidine
• C. Isopropyl alcohol
• D. Chlorine bleach

Correct answer: D

Rationale: Chlorine bleach is the recommended agent for cleaning blood spills due to its effectiveness in killing bloodborne pathogens like HIV and hepatitis B. Hydrogen peroxide, Chlorhexidine, and Isopropyl alcohol are not as effective as chlorine bleach in disinfecting surfaces contaminated with blood and eliminating bloodborne pathogens, making them incorrect choices.

2. A healthcare provider is caring for four clients. Which of the following tasks can the healthcare provider delegate to an assistive personnel?

• A. Perform chest compressions during cardiac resuscitation
• B. Perform a dressing change for a new amputee
• C. Assess the effectiveness of antiemetic medication
• D. Provide discharge instructions

Correct answer: A

Rationale: Performing chest compressions during cardiac resuscitation is a critical life-saving intervention that can be delegated to an assistive personnel during an emergency. This task requires immediate action and basic training, making it appropriate for delegation. Performing a dressing change for a new amputee involves specialized knowledge and skills, typically performed by licensed healthcare providers. Assessing the effectiveness of medication requires critical thinking and decision-making skills that are within the scope of a licensed healthcare provider. Providing discharge instructions involves educating the patient on post-discharge care and follow-up, which is typically done by a healthcare provider to ensure clear communication and understanding.

3. A client is experiencing suicidal thoughts and states, 'Why not end my misery?' What is the best response by the nurse?

• A. Why do you think your life isn’t worth living anymore?
• B. Do you have a plan to end your life?
• C. I need to understand what you mean by misery.
• D. You can trust me to share your thoughts.

Correct answer: B

Rationale: The correct answer is B: 'Do you have a plan to end your life?' When a client expresses suicidal thoughts, it is crucial to assess the immediate risk. Inquiring about a specific plan can help determine the seriousness of the situation. Choice A is less direct and may not provide a clear indication of the immediate risk. Choice C focuses on the interpretation of 'misery' rather than assessing the risk of suicide. Choice D offers support but does not address the critical assessment of the client's immediate safety.

4. A nurse is planning care for a client who has Alzheimer's disease and demonstrates confusion and wandering behavior. Which of the following should the nurse include in the plan of care?

• A. Place the client in seclusion when she is confused
• B. Request a prescription for PRN restraints when the client is wandering
• C. Dim the lighting in the client’s room
• D. Leave one side rail up on the client's bed

Correct answer: D

Rationale: The correct answer is to leave one side rail up on the client's bed. This action can help prevent falls while allowing the client to get up safely when needed, reducing the risk of injury from wandering. Placing the client in seclusion (Choice A) is not appropriate as it can lead to increased agitation and distress. Requesting restraints (Choice B) should be avoided as it can increase the risk of injuries and is not recommended for clients with Alzheimer's. Dimming the lighting (Choice C) may increase confusion and disorientation in clients with Alzheimer's disease.

5. A nurse is assessing a newborn who is 10 hours old. Which of the following findings should the nurse report to the provider?

• A. Axillary temperature 36.5°C (97.7°F)
• B. Nasal flaring
• C. Heart rate 158/min
• D. One void since birth

Correct answer: B

Rationale: Nasal flaring can indicate respiratory distress in a newborn, which is a critical finding requiring immediate attention. This may suggest an issue with breathing or lung function. Reporting nasal flaring promptly allows the provider to assess and intervene to ensure the newborn's respiratory status is stable. Choices A, C, and D are within normal parameters for a 10-hour-old newborn and do not indicate an immediate concern. An axillary temperature of 36.5°C (97.7°F) is within the normal range for a newborn. A heart rate of 158/min is typical for a newborn, and one void since birth is an expected finding at this early stage.

Similar Questions