Nursing Elites

1. A nurse is orienting a newly licensed nurse on performing a routine assessment of a client who is receiving mechanical ventilation via an endotracheal tube. Which of the following information should the nurse include in the teaching?

• A. Apply a vest restraint if self-extubation is attempted.
• B. Monitor ventilator settings every 8 hours.
• C. Document tube placement in centimeters at the angle of the jaw.
• D. Assess breath sounds every 1 to 2 hours.

Correct answer: D

Rationale: Assessing breath sounds every 1 to 2 hours is crucial in monitoring the client's respiratory status and identifying any potential complications promptly. Monitoring ventilator settings every 8 hours is important for overall ventilation management. Documenting the endotracheal tube placement accurately is essential to ensure proper positioning. Using a vest restraint if self-extubation is attempted is not a recommended intervention as it can lead to complications and should be avoided.

2. A healthcare professional is assessing a client who has experienced a left-hemispheric stroke. Which of the following is an expected finding?

• A. Impulse control difficulty
• B. Poor judgement
• C. Inability to recognize familiar objects
• D. Loss of depth perception

Correct answer: C

Rationale: Patients who have experienced a left-hemispheric stroke may exhibit symptoms of agnosia, which is the inability to recognize familiar objects or people. This occurs due to damage to the right hemisphere of the brain, which is responsible for visual and spatial perception. Impulse control difficulty, poor judgment, and loss of depth perception are not typically associated with left-hemispheric strokes.

3. The physician orders a platelet count to be performed on Mrs. Smith after breakfast. The nurse is responsible for:

• A. Instructing the patient about this diagnostic test
• B. Writing the order for this test
• C. Giving the patient breakfast
• D. All of the above

Correct answer: A

Rationale: The nurse's responsibility in this scenario is to instruct the patient about the diagnostic test ordered by the physician. This includes explaining the purpose of the test, any necessary preparations, and what to expect. The nurse is not responsible for writing the order, as this is the physician's role. Additionally, providing breakfast is not directly related to the platelet count test. Therefore, the correct answer is A, which aligns with the nurse's role in educating and supporting the patient regarding the test.

4. 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.

5. During a Romberg test, the patient is asked to assume which position?

• A. Sitting
• B. Standing
• C. Genupectoral
• D. Trendelenburg

Correct answer: B

Rationale: During a Romberg test, the patient is asked to stand with feet together and arms at the sides. The test evaluates proprioception and vestibular function by assessing the patient's ability to maintain balance with eyes closed. Asking the patient to stand helps to detect any balance issues or disturbances in the absence of visual input.

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