Nursing Elites

1. During the assessment of a client receiving packed RBCs, which finding indicates fluid overload?

• A. Low back pain.
• B. Dyspnea.
• C. Hypotension.
• D. Thready pulse.

Correct answer: B

Rationale: Dyspnea is a key finding indicating fluid overload in a client receiving packed RBCs. Fluid overload can lead to pulmonary edema, causing difficulty breathing or shortness of breath (dyspnea). Low back pain is not typically associated with fluid overload but can be more related to musculoskeletal issues. Hypotension and thready pulse are more indicative of hypovolemia (low fluid volume), not fluid overload.

2. After routine patient contact, how long should hand washing last at least?

• A. 30 seconds
• B. 1 minute
• C. 2 minutes
• D. 3 minutes

Correct answer: A

Rationale: Proper hand washing for 30 seconds is recommended after routine patient contact as it effectively removes pathogens. This duration ensures thorough cleaning without excessive time consumption, promoting infection control and prevention.

3. Palpating the midclavicular line is the correct technique for assessing

• A. Baseline vital signs
• B. Systolic blood pressure
• C. Respiratory rate
• D. Apical pulse

Correct answer: D

Rationale: Palpating the midclavicular line is the correct technique for assessing the apical pulse. The apical pulse is located at the point of maximal impulse (PMI), which is typically at the fifth intercostal space at the midclavicular line. This technique allows healthcare providers to accurately assess the heart rate and rhythm by listening to the heart sounds directly at this point.

4. When removing a contaminated gown, what should be the first thing touched by the nurse?

• A. Waist tie and neck tie at the back of the gown
• B. Waist tie in front of the gown
• C. Cuffs of the gown
• D. Inside of the gown

Correct answer: A

Rationale: When removing a contaminated gown, the nurse should ensure the first thing touched is the waist tie and neck tie at the back of the gown. This procedure helps prevent contamination by ensuring that the outer surface of the gown, which is likely to be contaminated, is not touched during removal. By touching the back ties first, the nurse minimizes the risk of transferring any contaminants to themselves or the environment.

5. A healthcare professional realizes that the wrong medication has been administered to a client. Which of the following actions should the healthcare professional take first?

• A. Notify the provider.
• B. Report the incident to the healthcare facility's manager.
• C. Monitor vital signs.
• D. Fill out an incident report.

Correct answer: C

Rationale: In a situation where the wrong medication has been administered to a client, the immediate priority is to assess and monitor the client's vital signs to identify any adverse effects of the incorrect medication. This action takes precedence over notifying the provider, reporting the incident, or filling out an incident report. Monitoring vital signs allows for timely recognition and intervention if the client experiences any negative reactions to the wrong medication, ensuring their safety and well-being.

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