Nursing Elites

1. A nurse at a long-term care facility is planning a fall prevention program for the residents. Which of the following interventions should the nurse include?

• A. Apply vest restraints to residents who are confused
• B. Keep all four side rails up on beds at night
• C. Accompany residents over 85 years of age during ambulation
• D. Implement rounds every 2 hours during the day to offer toileting

Correct answer: D

Rationale: The correct answer is to implement rounds every 2 hours during the day to offer toileting. This intervention helps prevent falls by addressing the common cause of unassisted mobility, which is the need to use the bathroom. Choice A is incorrect as restraints should not be the first choice for fall prevention due to the risk of injury and loss of independence. Choice B is incorrect because all side rails up can lead to entrapment and should only be used based on individualized assessments. Choice C may not be feasible for all residents over 85 years old and does not directly address the risk of falls.

2. A nurse in the emergency department is assessing a client who is unconscious following a motor-vehicle crash. The client requires immediate surgery. Which of the following actions should the nurse take?

• A. Transport the client to the operating room without verifying informed consent
• B. Ask the anesthesiologist to sign the consent
• C. Obtain telephone consent from the facility administrator before the surgery
• D. Delay the surgery until the nurse can obtain informed consent

Correct answer: A

Rationale: In emergency situations where a client is unconscious and requires immediate surgery, implied consent applies. Implied consent allows healthcare providers, including nurses, to proceed with necessary treatment or surgery without formally verifying informed consent. Choice A is correct because the priority in this scenario is to ensure the client receives timely medical intervention to address life-threatening conditions. Choices B, C, and D are incorrect because in emergencies, waiting to obtain formal consent can delay critical treatment, risking the client's health and well-being.

3. A nurse is comparing the rate of medication errors on the medical unit to the rate from a medical unit in a magnet hospital. Which of the following quality improvement methods is the nurse using?

• A. Structure audit
• B. Benchmarking
• C. Risk benefit analysis
• D. Root cause analysis

Correct answer: B

Rationale: The correct answer is B: Benchmarking. Benchmarking involves comparing performance metrics with those from other units or institutions, which is exactly what the nurse is doing by comparing the rate of medication errors on their medical unit to the rate from a medical unit in a magnet hospital. Choice A, Structure audit, is not relevant to this scenario as it focuses on assessing the physical, organizational, or procedural structures in a healthcare setting. Choice C, Risk benefit analysis, involves weighing the potential risks and benefits of a particular course of action, not comparing performance metrics. Choice D, Root cause analysis, is a method used to identify the underlying causes of problems or adverse events, not to compare performance metrics between units.

4. Select the tactile sensation that is accurately paired with its description or procedure for testing.

• A. Fine motor coordination: The use of the fingers
• B. Stereognosis: Equal hearing in both ears
• C. Two-point discrimination: The nurse gently pricks the patient's skin
• D. Gross motor function: The use of the lower limbs

Correct answer: C

Rationale: The correct answer is C: Two-point discrimination: The nurse gently pricks the patient's skin. Two-point discrimination assesses the ability to discern two points touched simultaneously on the skin. Fine motor coordination (Choice A) refers to the precise movements of small muscles, not related to tactile sensation. Stereognosis (Choice B) is the ability to recognize objects by touch, not equal hearing in both ears. Gross motor function (Choice D) involves the coordination of large muscle groups, not specifically related to tactile sensation testing.

5. What percentage of term newborns have a congenital heart disease due to environmental risk factors such as maternal alcoholism or drug ingestion?

• A. 2% to 4%
• B. 10% to 20%
• C. 5% to 10%
• D. 7% to 9%

Correct answer: A

Rationale: The correct answer is A: 2% to 4%. According to research, 2% to 4% of term newborns have congenital heart disease due to environmental risk factors such as maternal alcoholism or drug ingestion. Choices B, C, and D provide percentages that are higher than the actual prevalence of congenital heart disease in newborns caused by environmental factors, making them incorrect.

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