Nursing Elites

1. When preparing for a change of shift, which document or tools should a healthcare provider use to communicate?

• A. SBAR
• B. SOAP
• C. PIE
• D. DAR

Correct answer: A

Rationale: The correct answer is A: SBAR (Situation, Background, Assessment, Recommendation) is a structured method for communicating information during shift changes. SBAR provides a clear and concise way for healthcare providers to communicate important details about a patient's condition, ensuring that essential information is effectively transferred between providers. Choice B, SOAP (Subjective, Objective, Assessment, Plan), is a method primarily used for documentation in patient charts, not for shift change communication. Choice C, PIE (Problem, Intervention, Evaluation), is a nursing process format for organizing nursing care that focuses on individualized patient care plans, not shift handoff communication. Choice D, DAR (Data, Action, Response), is not a standard format for provider-to-provider handoff communication and is less commonly used in healthcare settings compared to SBAR.

2. An older adult male client is admitted to the medical unit following a fall at home. When undressing him, the nurse notes that he is wearing an adult diaper and skin breakdown is obvious over his sacral area. What action should the nurse implement first?

• A. Establish a toileting schedule to decrease episodes of incontinence
• B. Complete a functional assessment of the client's self-care abilities
• C. Apply a barrier ointment to intact areas that may be exposed to moisture
• D. Determine the size and depth of skin breakdown over the sacral area

Correct answer: D

Rationale: The first action the nurse should implement is to determine the size and depth of the skin breakdown over the sacral area. This initial assessment will provide crucial information on the extent of the damage and guide appropriate care interventions. Option A is not the priority in this scenario as the immediate concern is addressing the existing skin breakdown. Option B, completing a functional assessment, is important but should come after addressing the acute issue of skin breakdown. Option C, applying a barrier ointment, may be beneficial later but does not address the primary need of assessing the extent of the current skin damage.

3. A healthcare professional is planning to perform ear irrigation on an adult client with impacted cerumen. Which of the following should the professional plan to take?

• A. Wearing sterile gloves while performing irrigation
• B. Positioning the client with the affected side down following irrigation
• C. Using cool fluid to irrigate the ear canal
• D. Pulling the pinna downward during irrigation

Correct answer: B

Rationale: Positioning the client with the affected side down following irrigation is crucial as it helps facilitate drainage of the dislodged cerumen and any remaining irrigation solution. This position allows gravity to assist in the removal of the loosened debris. Wearing sterile gloves is a standard precaution in healthcare procedures to prevent infection but is not specific to ear irrigation. Using body-temperature water or a solution at a slightly warmer temperature is recommended to prevent vertigo and discomfort, so using cool fluid is incorrect. Pulling the pinna upward and backward, not downward, straightens the ear canal for adults to facilitate the irrigation process, making choice D incorrect.

4. While reviewing the medical records of a client with a pressure ulcer, a nurse should expect which of the following findings?

• A. Albumin level of 3 g/dL
• B. Hemoglobin level of 12 g/dL
• C. WBC count of 6,000/mm³
• D. Blood glucose level of 100 mg/dL

Correct answer: A

Rationale: An albumin level below 3.5 g/dL indicates protein deficiency, which can impair wound healing and contribute to pressure ulcer formation. Hemoglobin level and WBC count are not directly associated with pressure ulcers. Blood glucose level, while important for overall health, is not specifically linked to pressure ulcer development.

5. When assessing readiness to learn about insulin self-administration, what indicates the client is ready to learn?

• A. I can concentrate best in the morning.
• B. I feel anxious about learning the process.
• C. I have a lot of questions about insulin.
• D. I am not sure if I can manage this at home.

Correct answer: A

Rationale: The correct answer is A: 'I can concentrate best in the morning.' Readiness to learn is indicated by the client's ability to focus and concentrate, as mentioned in the question. Choice B, 'I feel anxious about learning the process,' indicates apprehension and may hinder the learning process. Choice C, 'I have a lot of questions about insulin,' shows interest but does not directly indicate readiness to learn. Choice D, 'I am not sure if I can manage this at home,' reflects uncertainty and lack of confidence, which may suggest the client is not fully prepared to learn.

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