Nursing Elites

1. A nurse is caring for her clients when her new admit arrives on the unit. What action by the nurse is most appropriate?

• A. Ask the nursing assistant to complete emptying the catheter bag and assess the new admission.
• B. Ask the nursing assistant to take vital signs on the new admit and begin the history until she can get there.
• C. Ask the graduate nurse on the floor to initiate the assessment process until she can get there.
• D. Ask the unit secretary to make the client and family comfortable until she can complete her present task.

Correct answer: C

Rationale: The most appropriate action for the nurse in this situation is to ask the graduate nurse on the floor to initiate the assessment process until she can arrive. Nursing assistants are not qualified to perform assessments, and the unit secretary's role does not involve client assessments. Delegating the assessment to the graduate nurse ensures that a qualified healthcare professional is evaluating the new admission, aligning with the nurse's responsibilities and providing appropriate care.

2. When encountering the significant other of a patient with end-stage AIDS crying during her smoke break, what is the most appropriate action for the nurse to take?

• A. Allow her to grieve by herself.
• B. Tell her to go ahead and cry, after all, your husband’s pretty bad off.
• C. Tell her you realize how upset she is, but you don’t want to talk about it now.
• D. Approach her, offering tissues, and encourage her to verbalize her feelings

Correct answer: D

Rationale: Approaching the significant other, offering tissues, and encouraging her to verbalize her feelings is the most appropriate action for the nurse to take. Being left alone during the grief process isolates individuals, and they need an outlet for their feelings. By showing empathy and providing support, the nurse can help the significant other cope with her emotions. Choices A, B, and C are inappropriate because they do not offer support or encourage the expression of feelings, which are crucial in such situations.

3. Nurses should understand the chain of infection because it refers to:

• A. the linkages involved in disease transmission.
• B. the sequence required for transmission of disease.
• C. the clustering of bacteria in a specific pattern.
• D. increasing virulence patterns among microorganisms.

Correct answer: B

Rationale: The chain of infection refers to the sequence required for the transmission of disease, involving steps like the pathogen's presence, movement from a reservoir, and entry into a susceptible host. Understanding this sequence helps healthcare professionals, including nurses, in implementing effective infection control measures. Choices A, C, and D are incorrect because they do not accurately describe the concept of the chain of infection. Choice A is too broad and does not specifically address the sequential nature of disease transmission. Choice C focuses on bacterial clustering rather than the transmission process. Choice D mentions virulence patterns, which are not the primary focus of the chain of infection concept.

4. If your patient is acutely psychotic, which of the following independent nursing interventions would not be appropriate?

• A. Conveying calmness through one-on-one interaction
• B. Recognizing and managing your own feelings to prevent escalation of the patient's anxiety level
• C. Encouraging client participation in group therapy
• D. Listening and identifying causes of their behavior

Correct answer: C

Rationale: When a patient is acutely psychotic, they may not be able to effectively participate in group therapy due to their altered mental state. Group settings can be overwhelming and may exacerbate the patient's symptoms. Choices A, B, and D are appropriate interventions. Choice A is correct as providing calmness through one-on-one interaction can be beneficial in establishing trust and reducing anxiety. Choice B is also important as recognizing and managing the nurse's feelings can prevent further escalation of the patient's symptoms. Choice D is relevant as listening and identifying causes of the patient's behavior can aid in understanding and providing appropriate care tailored to the patient's needs.

5. What is the priority nursing action for a laboring client dilated to 6 cm receiving an epidural?

• A. Continuous monitoring of maternal blood pressure.
• B. Frequent auscultation of the fetal heart rate.
• C. Administering an IV fluid bolus of at least 500 cc.
• D. Frequent monitoring of the maternal temperature.

Correct answer: A

Rationale: The priority nursing action for a laboring client dilated to 6 cm receiving an epidural is continuous monitoring of maternal blood pressure. This is crucial because epidural anesthesia can lead to a precipitous drop in blood pressure, which can be dangerous for both the mother and fetus by reducing cardiac output and placental perfusion. While frequent auscultation of the fetal heart rate is important, it is not the priority in this situation. Administering an IV fluid bolus of at least 500 cc may not be necessary if the client's blood pressure is stable. Monitoring the maternal temperature is also essential but takes precedence over blood pressure monitoring.

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