Nursing Elites

1. A client enters the emergency department unconscious via ambulance from the client's workplace. What document should be given priority to guide the direction of care for this client?

• A. The statement of client rights and the client self-determination act
• B. Orders written by the healthcare provider
• C. A notarized original copy of advance directives brought in by the partner
• D. The clinical pathway protocol of the agency and the emergency department

Correct answer: C

Rationale: In the scenario described, when a client arrives unconscious, priority should be given to a notarized original copy of advance directives brought in by the partner. Advance directives are legal documents that specify a person's healthcare wishes and decision-making preferences in advance. These directives guide healthcare providers in delivering care according to the client's preferences when the client is unable to communicate. The statement of client rights and the client self-determination act (Choice A) are important but do not provide specific care instructions. Orders written by the healthcare provider (Choice B) may not reflect the client's wishes. Clinical pathway protocols (Choice D) are valuable but do not address the individualized care preferences of the client.

2. A charge nurse is observing a newly licensed nurse prepare a sterile field. Which of the following actions should the charge nurse identify as contaminating the sterile field?

• A. The nurse opens the sterile field on a wet surface.
• B. The nurse turns away from the sterile field.
• C. The nurse uses a non-sterile glove to touch the sterile field.
• D. The nurse touches the edge of the sterile drape with her hand.

Correct answer: A

Rationale: The correct answer is A. Opening the sterile field on a wet surface contaminates it, rendering it unsafe for use. Moisture can carry microorganisms that can compromise the sterility of the field. Choice B is incorrect because turning away from the sterile field alone does not necessarily contaminate it unless the nurse touches non-sterile items. Choice C is incorrect because using a non-sterile glove to touch the sterile field directly introduces contaminants. Choice D is incorrect as touching the edge of the sterile drape with a hand may not necessarily contaminate the entire field, unlike opening it on a wet surface.

3. While suctioning a client's nasopharynx, the nurse observes that the client's oxygen saturation remains at 94%, which is the same reading obtained prior to starting the procedure. What action should the nurse take in response to this finding?

• A. Complete the intermittent suction of the nasopharynx.
• B. Reposition the pulse oximeter clip to obtain a new reading.
• C. Stop suctioning until the pulse oximeter reading is above 95%.
• D. Apply an oxygen mask over the client's nose and mouth.

Correct answer: A

Rationale: The correct action for the nurse to take in this situation is to complete the intermittent suction of the nasopharynx. Since the oxygen saturation remains stable at 94%, which was the initial reading, it indicates that the procedure is not causing a significant drop in oxygen levels. Stopping the suctioning or applying oxygen may not be necessary as the saturation level is within an acceptable range. Repositioning the pulse oximeter clip is unlikely to change the reading significantly. Therefore, completing the procedure maintains care consistency and effectiveness, ensuring proper airway management without unnecessary interventions. Choices B, C, and D are incorrect because repositioning the pulse oximeter clip, stopping suctioning until a higher reading is achieved, and applying oxygen are not warranted based on the stable oxygen saturation level of 94% throughout the procedure.

4. A healthcare professional is reviewing a client's health record and notes a new prescription for lisinopril 10 mg PO once daily. The healthcare professional should identify this as which of the following types of prescription?

• A. Single
• B. Stat
• C. Routine
• D. Now

Correct answer: C

Rationale: A routine prescription, such as lisinopril 10 mg PO once daily, is administered on a regular schedule with or without a termination date. It is a standard, ongoing prescription for maintenance therapy. Choice A, 'Single,' would typically refer to a one-time prescription. Choice B, 'Stat,' is used for prescriptions that are needed immediately or in emergency situations. Choice D, 'Now,' is not a common prescription type designation and is not applicable in this context.

5. A client is receiving teaching from a healthcare provider about reducing the adverse effects of immobility. Which of the following statements by the client indicates an understanding of the teaching?

• A. I will perform ankle and knee exercises every hour - Range of motion (ROM) is needed to prevent contractures.
• B. I will hold my breath when rising from a sitting position.
• C. I will remove my antiembolic stockings while I am in bed.
• D. I will have my partner help me change positions every 4 hours.

Correct answer: A

Rationale: Choice A is correct because performing ankle and knee exercises every hour helps prevent contractures and other adverse effects of immobility. Contractures are a common complication of immobility, and range of motion (ROM) exercises can help maintain joint flexibility and prevent contractures. This statement indicates an understanding of the teaching provided by the healthcare provider. Choices B, C, and D are incorrect. Holding the breath when rising from a sitting position can increase the risk of orthostatic hypotension, not reduce adverse effects of immobility. Removing antiembolic stockings while in bed can compromise their effectiveness in preventing deep vein thrombosis (DVT), which is not a measure to reduce immobility-related complications. Having a partner help change positions every 4 hours may not be frequent enough to prevent immobility-related complications effectively; changing positions more frequently is usually recommended to prevent issues like pressure ulcers and muscle stiffness.

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