Nursing Elites

1. A client with a broken femur is in a traction splint in bed. Which of the following interventions is NOT part of caring for this client?

• A. Palpating the temperature of both feet
• B. Evaluating pulses bilaterally
• C. Turning the client to a side-lying position
• D. Relieving heel pressure by placing a pillow under the foot

Correct answer: C

Rationale: When caring for a client with a broken femur in a traction splint, turning the client to a side-lying position is not recommended. This client is at risk of skin breakdown and complications due to the injury, making it important to prevent unnecessary movement that may increase the risk of injury or discomfort. Palpating the temperature of both feet helps in assessing circulation, evaluating pulses bilaterally ensures perfusion to the extremities, and relieving heel pressure by placing a pillow under the foot helps in reducing pressure points and preventing complications like pressure ulcers. Therefore, the correct answer is turning the client to a side-lying position as it is not a recommended intervention in this scenario.

2. What might be signaled when a client tells the nurse to 'pray for me' and entrusts her wedding ring to the nurse?

• A. Anxiety
• B. Suicidal ideation
• C. Major depression
• D. Hopelessness

Correct answer: B

Rationale: The client entrusting the wedding ring and asking the nurse to pray for them can be indicative of suicidal ideation. This behavior suggests a deep level of distress and hopelessness, potentially leading to suicidal thoughts or actions. While anxiety is a common emotion, the act of entrusting personal items and making requests like praying for them go beyond typical anxiety symptoms. Major depression can be associated with suicidal ideation, but the specific actions described in this scenario point more towards suicidal thoughts. Hopelessness, while related to suicidal ideation, is a broader concept that does not capture the specific cues given by the client in this scenario, making it a less accurate choice.

3. The nurse is caring for a woman 2 hours after a vaginal delivery. Documentation indicates that the membranes were ruptured for 36 hours prior to delivery. What are the priority nursing diagnoses at this time?

• A. Altered tissue perfusion
• B. Risk for fluid volume deficit
• C. High risk for hemorrhage
• D. Risk for infection

Correct answer: D

Rationale: The correct answer is 'Risk for infection.' When membranes are ruptured for over 24 hours before delivery, there is a significantly increased risk of infection for both the mother and the newborn. Factors such as increased local cytokines, an imbalance in enzyme activity, and increased intrauterine pressure contribute to this risk. 'Altered tissue perfusion' is not the priority in this scenario as there is no indication of compromised blood flow. 'Risk for fluid volume deficit' is not the priority as there are no signs of excessive fluid loss. 'High risk for hemorrhage' is not the priority as the question does not suggest active bleeding as an immediate concern.

4. OSHA has very strict standards for hospital employees who may encounter hazardous materials or patients who have been exposed to them. These regulations include all of the following EXCEPT:

• A. Respiratory protection must be provided to all employees who might be exposed.
• B. Training on respiratory protection must be provided.
• C. Employers must provide personal protective equipment to all employees.
• D. All ED personnel must be trained in decontamination procedures.

Correct answer: D

Rationale: OSHA regulations for hospital employees dealing with hazardous materials or exposed patients require respiratory protection for potentially exposed employees, training on respiratory protection, and the provision of personal protective equipment. However, not all ED personnel are required to be trained in decontamination procedures. While all ED staff should have a basic understanding of hazmat situations, specific training in decontamination procedures is only necessary for those who will be directly involved in the decontamination process. Therefore, the correct answer is that all ED personnel must be trained in decontamination procedures, as this is not a mandatory requirement under OSHA regulations for hospital employees who may encounter hazardous materials or exposed patients.

5. While assessing a one-month-old infant, which of the findings does not warrant further investigation by the nurse?

• A. Abdominal respirations
• B. Inspiratory grunt
• C. Nasal flaring
• D. Cyanosis

Correct answer: A

Rationale: Abdominal respirations in infants are considered normal due to the underdeveloped intercostal muscles. Infants rely more on their abdominal muscles to facilitate breathing since their intercostal muscles are not fully matured. Therefore, abdominal respirations do not typically require further investigation. Inspiratory grunt, nasal flaring, and cyanosis are findings that warrant additional assessment as they can indicate potential respiratory distress or other underlying health issues in infants. Inspiratory grunt may suggest respiratory distress, nasal flaring can be a sign of increased work of breathing, and cyanosis indicates poor oxygenation, all of which require prompt evaluation and intervention to ensure the infant's well-being.

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