Nursing Elites

1. When assessing the skin of an immobilized patient, what should the nurse do?

• A. Assess the skin every 4 hours.
• B. Limit the amount of fluid intake.
• C. Use a standardized tool such as the Braden Scale.
• D. Have special times for inspection to not interrupt routine care.

Correct answer: C

Rationale: When assessing the skin of an immobilized patient, it is essential to use a standardized tool like the Braden Scale. This tool helps in systematically evaluating the patient's risk of developing pressure ulcers. Assessing the skin every 4 hours (Choice A) may be too frequent or unnecessary unless there are specific concerns or orders. Limiting fluid intake (Choice B) is not directly related to skin assessment in an immobilized patient. Having special times for inspection to avoid interrupting routine care (Choice D) is not as crucial as using a standardized tool for consistent and comprehensive skin assessment.

2. While measuring a client’s vital signs, the nurse notices an irregularity in the heart rate. Which nursing action is appropriate?

• A. Count the apical pulse rate for 1 full minute, and describe the rhythm in the chart
• B. Measure the blood pressure
• C. Perform an ECG
• D. Recheck the heart rate after 5 minutes

Correct answer: A

Rationale: The appropriate nursing action when an irregularity in the heart rate is observed is to count the apical pulse rate for a full minute and describe the rhythm in the chart. This approach helps in obtaining an accurate assessment of the irregularities present. Measuring the blood pressure (Choice B) is important but not the immediate priority when an irregular heart rate is noted. Performing an ECG (Choice C) may be necessary but is a more advanced intervention that should follow the initial assessment. Rechecking the heart rate after 5 minutes (Choice D) may delay potential interventions for addressing the irregularity, making it less appropriate than the immediate assessment and documentation of the pulse rhythm.

3. When reviewing car seat use with the parents of a 1-month-old infant, which of the following instructions should the nurse include?

• A. Use a car seat that has a three-point harness system.
• B. Position the car seat so that the infant is rear-facing.
• C. Secure the car seat in the front passenger seat of the vehicle.
• D. Convert to a booster seat after 12 months.

Correct answer: B

Rationale: The correct instruction for car seat use with a 1-month-old infant is to position the car seat so that the infant is rear-facing. This orientation provides the safest option for infants as it supports their head, neck, and spine. While using a car seat with a three-point harness system is appropriate for infants, placing the car seat in the front passenger seat is not recommended due to the presence of airbags, which can pose a risk to the infant in the event of deployment. Additionally, transitioning to a booster seat is not suitable at 12 months; infants should remain in rear-facing car seats until they outgrow the seat's height or weight limits, typically around 2 years of age.

4. The charge nurse has a health care team that consists of 1 PN, 1 unlicensed assistive personnel (UAP), and 1 PN nursing student. Which assignment should be questioned by the nurse manager?

• A. An admission at the change of shifts with atrial fibrillation and heart failure - PN
• B. Client who had a major stroke 6 days ago - PN nursing student
• C. A child with burns who has packed cells and albumin IV running - charge nurse
• D. An elderly client who had a myocardial infarction a week ago - UAP

Correct answer: A

Rationale: Assigning an admission with atrial fibrillation and heart failure to a PN is not appropriate. This complex case requires more advanced skills and should not be managed by a PN without adequate support. The PN may not have the necessary training or expertise to handle such a critical situation effectively. Choice B is a suitable assignment for a PN nursing student as they can handle a client who had a major stroke 6 days ago. Choice C is also appropriate as a child with burns receiving packed cells and albumin IV running can be managed by the charge nurse. Choice D is within the scope of practice for a UAP since an elderly client post-myocardial infarction a week ago may require basic care and assistance.

5. The nurse is caring for a client who is post-operative following a cholecystectomy. Which assessment finding would require immediate intervention?

• A. Absent bowel sounds
• B. Pain level of 8/10
• C. Temperature of 100.4°F
• D. Saturated abdominal dressing

Correct answer: D

Rationale: A saturated abdominal dressing may indicate active bleeding or other complications that require immediate intervention, such as ensuring hemostasis and preventing further complications. Absent bowel sounds are common in the immediate post-operative period and may not require immediate intervention unless accompanied by other symptoms. A pain level of 8/10 can be managed with appropriate pain medication and is not typically considered an immediate priority unless other indications suggest complications. A temperature of 100.4°F is slightly elevated but may not be a cause for immediate concern unless it is associated with other signs of infection or distress that would warrant urgent attention.

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