Nursing Elites

1. A client is having difficulty breathing while laying in bed with a nasal cannula delivering oxygen. Which of the following interventions should the nurse take first?

• A. Suction the client's airway
• B. Administer a bronchodilator
• C. Increase the humidity in the client's room
• D. Assist the client to an upright position

Correct answer: D

Rationale: The correct answer is to assist the client to an upright position. When a client is having difficulty breathing, promoting optimal oxygenation is essential. Elevating the head of the bed improves ventilation and lung expansion by reducing pressure on the diaphragm. This position allows the lungs to expand fully, enhancing oxygen exchange. Suctioning the airway may be necessary if there are secretions causing obstruction, but it is not the first intervention in this scenario. Administering a bronchodilator is appropriate for bronchoconstriction but does not address the immediate need for better ventilation. Increasing humidity can be beneficial in certain respiratory conditions, but it is not the initial priority when a client is struggling to breathe.

2. A nurse is counseling a young adult who describes having difficulty dealing with several issues. Which of the following statements should the nurse identify as the priority to assess further?

• A. “I have my own apartment now, but it’s not easy living away from my guardians.”
• B. “It’s been so stressful for me to even think about having my own family.”
• C. “I don’t even know who I am yet, and now I’m supposed to know what to do.”
• D. “My partner is pregnant, and I don’t think I have what it takes to be a good parent.”

Correct answer: D

Rationale: The statement about feeling unprepared to be a good parent indicates a significant concern that may need further assessment and support. This statement raises issues regarding the individual's readiness for parenthood and potential impact on the partner and the unborn child. Choices A, B, and C, while important, do not present immediate concerns regarding the well-being of another individual and do not raise potential risks that could have a direct impact on others.

3. When moving a patient up in bed using a drawsheet with the help of another nurse, in which order will the nurses perform the steps, starting with the first one?

• A. Grasp the drawsheet firmly near the patient.
• B. Move the patient and drawsheet to the desired position.
• C. Position one nurse at each side of the bed.
• D. Place the drawsheet under the patient from shoulder to thigh.

Correct answer: C

Rationale: When moving a patient up in bed with a drawsheet and the assistance of another nurse, it is important to have one nurse positioned at each side of the bed initially. This allows for proper coordination and support during the patient movement. Placing the drawsheet under the patient from shoulder to thigh, grasping the drawsheet firmly near the patient, and moving the patient and drawsheet to the desired position follow after the nurses are positioned on each side of the bed. The correct sequence ensures a safe and coordinated approach to repositioning the patient in bed.

4. A patient requires repositioning every 2 hours. Which task can the nurse delegate to the nursing assistive personnel?

• A. Determining the level of comfort
• B. Changing the patient's position
• C. Identifying immobility hazards
• D. Assessing circulation

Correct answer: B

Rationale: The correct answer is B: 'Changing the patient's position.' Repositioning the patient involves physically moving and adjusting their position in bed, which is a task that can be safely delegated to nursing assistive personnel (NAP). This task does not require clinical judgment or assessment skills beyond the ability to follow guidelines for proper positioning. Choices A, C, and D involve assessments or judgments that require a higher level of training and knowledge, making them more appropriate for a nurse to perform. Choice A involves assessing comfort, which may involve subjective factors and individual preferences. Choice C involves identifying hazards related to immobility, which requires understanding the potential risks and complications associated with immobility. Choice D involves assessing circulation, which requires a higher level of clinical knowledge and understanding of circulatory issues.

5. The nurse in the emergency department observes a colleague viewing the electronic health record (EHR) of a client who holds an elected position in the community. The client is not a part of the colleague's assignment. Which action should the nurse implement?

• A. Communicate the colleague's actions to the unit charge nurse
• B. Send an email to facility administration reporting the action
• C. Write an anonymous complaint to a professional website
• D. Post a comment about the action on a staff discussion board

Correct answer: A

Rationale: Communicating the colleague's actions to the unit charge nurse is the most appropriate action to take in this scenario. Reporting to the charge nurse follows proper protocol and ensures privacy compliance. This option allows for addressing the issue internally within the healthcare setting, maintaining confidentiality, and following the chain of command. Sending an email to facility administration (Choice B) might be premature without internal investigation and could potentially bypass the immediate supervisor who is responsible for addressing such issues. Writing an anonymous complaint to a professional website (Choice C) and posting a comment about the action on a staff discussion board (Choice D) are not professional or effective ways to address the situation, as they do not ensure proper handling of the breach of privacy within the organization.

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