Nursing Elites

1. A healthcare professional is preparing to perform nasal tracheal suctioning for a client. Which of the following is an appropriate action for the healthcare professional to take?

• A. Hold the suction catheter with the non-dominant hand.
• B. Apply suctioning for 20 to 30 seconds.
• C. Place the catheter in a clean and dry location for later use.
• D. Use surgical asepsis when performing the procedure.

Correct answer: D

Rationale: Using surgical asepsis when performing nasal tracheal suctioning is crucial to prevent infection. Choice A is incorrect because the suction catheter should be held with the dominant hand to ensure better control and precision during the procedure. Choice B is incorrect as suctioning should be applied for no longer than 10 to 15 seconds to avoid trauma to the mucous membranes. Choice C is incorrect as the catheter should be disposed of properly after single-use to prevent cross-contamination and infection.

2. Which action by the nurse will be the most important for preventing skin impairment in a mobile patient with local nerve damage?

• A. Insert an indwelling urinary catheter.
• B. Limit caloric and protein intake.
• C. Turn the patient every 2 hours.
• D. Assess for pain during a bath.

Correct answer: D

Rationale: The most important action for preventing skin impairment in a mobile patient with local nerve damage is to assess for pain during a bath. Assessing pain during a bath helps in evaluating sensory nerve function by checking for touch, pain, heat, cold, and pressure. This assessment is crucial in identifying areas of potential skin breakdown and implementing preventive measures. Inserting an indwelling urinary catheter (Choice A) is not directly related to preventing skin impairment in this context. Limiting caloric and protein intake (Choice B) is not pertinent to skin impairment prevention for a mobile patient with local nerve damage. While turning the patient every 2 hours (Choice C) is a good practice for preventing pressure ulcers, in this case, assessing for pain during a bath is more directly related to preventing skin impairment associated with nerve damage.

3. The nurse is admitting a patient diagnosed with a stroke. The healthcare provider writes orders for 'ROM as needed.' What should the nurse do next?

• A. Restrict the patient's mobility as much as possible.
• B. Realize the patient is unable to move extremities.
• C. Move all the patient's extremities.
• D. Further assess the patient.

Correct answer: D

Rationale: The correct answer is to further assess the patient. 'ROM as needed' stands for Range of Motion, indicating that the patient should have their limbs moved to maintain joint flexibility and muscle strength. Before initiating any movements, it is crucial to assess the patient's current condition to determine their abilities and limitations. Restricting mobility (choice A) is not appropriate as it contradicts the purpose of ROM exercises. Realizing the patient is unable to move extremities (choice B) assumes without assessment and can lead to inappropriate care. Moving all the patient's extremities (choice C) without assessing the patient first can be harmful, as it may cause pain or injury if done incorrectly. Therefore, further assessment is necessary to provide safe and effective care.

4. A female client's significant other has been at her bedside providing reassurances and support for the past 3 days, as desired by the client. The client's estranged husband arrives and demands that the significant other not be allowed to visit or be given condition updates. Which intervention should the nurse implement?

• A. Obtain a perception from the healthcare provider regarding visitation privileges
• B. Request a consultation with the ethics committee for resolution of the situation
• C. Encourage the client to speak with her husband regarding his disruptive behavior
• D. Communicate the client's wishes to all members of the multidisciplinary team

Correct answer: D

Rationale: The correct intervention is to communicate the client's wishes to all members of the multidisciplinary team. This action respects the client's autonomy and maintains her comfort by ensuring that her desires regarding visitation and support are known and upheld. Obtaining a perception from the healthcare provider regarding visitation privileges (Choice A) may not fully consider the client's preferences. Requesting a consultation with the ethics committee (Choice B) may be premature and could delay prompt resolution of the issue. Encouraging the client to speak with her husband (Choice C) may not be appropriate, as the husband's demands are disrupting the client's care and comfort, and the client may not feel safe or comfortable doing so.

5. While starting an intravenous infusion (IV) for a client, the nurse notices that her gloved hands get spotted with blood. The client has not been diagnosed with any infection transmitted via the bloodstream. Which of the following should the nurse do as soon as the task is completed?

• A. Remove the gloves carefully and follow with hand hygiene
• B. Change gloves and continue
• C. Wash hands immediately without removing gloves
• D. Report the incident to the supervisor

Correct answer: A

Rationale: After completing the task, the nurse should remove the gloves carefully and follow with hand hygiene. This practice is crucial to prevent the transmission of any potential pathogens, maintain cleanliness, and reduce the risk of infection. Changing gloves and continuing without proper hand hygiene may lead to contamination. Washing hands immediately without removing gloves is not recommended as it does not ensure thorough hand hygiene. Reporting the incident to the supervisor should be done if there are specific protocols in place for such incidents, but immediate hand hygiene is the priority in this scenario to ensure patient and nurse safety.

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