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 nurse is preparing to check a client's blood pressure. Which of the following actions should the nurse take?

• A. Apply the cuff above the client's antecubital fossa.
• B. Use a cuff with a width that is about 60% of the client's arm circumference.
• C. Have the client sit with their arm resting at the level of their heart.
• D. Release the pressure on the client's arm at a rate of 5 to 6 mm per second.

Correct answer: A

Rationale: The correct action when checking a client's blood pressure is to apply the cuff above the client's antecubital fossa. Placing the cuff above this area allows for an accurate measurement of blood pressure. Choice B is incorrect because the cuff width should be approximately 40% of the arm circumference, not 60%. Choice C is incorrect as the client's arm should rest at heart level, not above it, to ensure an accurate reading. Choice D is incorrect as the pressure on the client's arm should be released at a rate of 2 to 3 mm per second, not 5 to 6 mm per second.

3. While documenting in a client’s medical record, which of the following entries should the nurse record?

• A. “Incision without redness or drainage”
• B. “Drank adequate amounts of fluid with meals”
• C. “Administered pain medication”
• D. “Oral temperature slightly elevated at 0800”

Correct answer: D

Rationale: The correct answer is D because documenting specific observations, such as an oral temperature being slightly elevated at a specific time, is crucial for monitoring the client's health status accurately. This type of information helps in assessing trends and changes in the client's condition over time. Choice A is incorrect as it lacks specificity and does not provide measurable data about the client's condition. Choice B is incorrect because it is a general statement related to client behavior rather than a specific health observation. Choice C is incorrect as it reflects an action taken by the nurse and not a direct client's condition or observation.

4. The nurse is providing care for a client with a wound infection. Which type of precautions should the nurse implement?

• A. Airborne precautions
• B. Droplet precautions
• C. Contact precautions
• D. Standard precautions

Correct answer: C

Rationale: Contact precautions are necessary when caring for a client with a wound infection to prevent the spread of infection. Contact precautions involve practices such as wearing gloves and gowns, and ensuring proper hand hygiene. Airborne precautions are for diseases transmitted by small droplet nuclei that can remain suspended in the air, like tuberculosis. Droplet precautions are for diseases transmitted through respiratory droplets larger than 5 microns, such as influenza. Standard precautions are used for all clients to prevent the spread of infection and include practices like hand hygiene, use of personal protective equipment, and safe injection practices. In this case, since the client has a wound infection, the nurse should focus on implementing contact precautions to reduce the risk of spreading the infection to themselves or others.

5. The nurse has admitted a 4-year-old with the diagnosis of possible rheumatic fever. Which statement by the parent would cause the nurse to suspect an association with this disease?

• A. Our child had chickenpox 6 months ago.
• B. Strep throat went through all the children at the day care last month.
• C. Both ears were infected over 3 months ago.
• D. Last week both feet had a fungal skin infection.

Correct answer: B

Rationale: The correct answer is B. Rheumatic fever often follows a strep throat infection, which is why the nurse should suspect this association. Strep throat is caused by Group A Streptococcus bacteria, which can trigger an abnormal immune response leading to rheumatic fever. Choices A, C, and D are incorrect because chickenpox, ear infections, and fungal skin infections are not typically associated with rheumatic fever.

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