Nursing Elites

1. While receiving a change of shift report on a group of clients, which patient should the nurse assess first?

• A. The client who has a fractured femur and reports sharp chest pain.
• B. The client who has a fever and is receiving antibiotics.
• C. The client who has a urinary tract infection and reports pain with urination.
• D. The client who is scheduled for surgery in the afternoon.

Correct answer: A

Rationale: The nurse should assess the client with a fractured femur and sharp chest pain first. Sharp chest pain in this client may indicate a pulmonary embolism, a life-threatening condition requiring immediate attention. The other options describe important patient conditions but do not pose an immediate threat to life like a potential pulmonary embolism does.

2. A nurse is caring for a client with Alzheimer's disease. Which action should the nurse include in the care plan to support the client’s cognitive function?

• A. Place a daily calendar in the kitchen
• B. Replace buttoned clothing with zippered items
• C. Replace carpet with hardwood floors
• D. Create variation in the daily routine

Correct answer: A

Rationale: Placing a daily calendar in the kitchen is beneficial for clients with Alzheimer's disease as it helps in orienting them to time and enhances cognitive function. This visual aid can assist in keeping track of days and activities. Choice B, replacing buttoned clothing with zippered items, is more related to promoting independence in dressing rather than directly supporting cognitive function. Choice C, replacing carpet with hardwood floors, focuses on safety and mobility rather than cognitive function. Choice D, creating variation in the daily routine, may be helpful for engagement and stimulation but does not directly address cognitive function as effectively as using a daily calendar.

3. A nurse is planning care for a client who has chronic kidney disease. Which finding indicates the need for hemodialysis?

• A. BUN 14 mg/dL
• B. Serum potassium 4.2 mEq/L
• C. Serum creatinine 5 mg/dL
• D. Serum calcium 9 mg/dL

Correct answer: C

Rationale: The correct answer is C. A serum creatinine level of 5 mg/dL is significantly elevated and indicates the need for hemodialysis to help filter waste products from the blood. Elevated creatinine levels suggest impaired kidney function and the inability to effectively filter waste from the body. Choices A, B, and D are within normal ranges and do not indicate the need for immediate hemodialysis in a client with chronic kidney disease.

4. A nurse is discussing immunity with a client who has received an immunization. The nurse should identify that an immunization functions as part of which type of immunity?

• A. Innate immunity
• B. Passive immunity
• C. Acquired immunity
• D. Natural immunity

Correct answer: C

Rationale: The correct answer is C: Acquired immunity. Acquired immunity occurs when an individual is given a vaccine or immunization to develop antibodies. This type of immunity is specific and develops after exposure to an antigen. Innate immunity (choice A) is the body's natural defense system present at birth. Passive immunity (choice B) is temporary immunity passed from one individual to another. Natural immunity (choice D) refers to immunity that is not gained through medical intervention or deliberate exposure.

5. A nurse is caring for a newborn in the nursery following a circumcision. The newborn's grandparent, who does not have an identification bracelet, requests to take the newborn to his mother's room. What action should the nurse take?

• A. Notify security.
• B. Respectfully deny the grandparent’s request.
• C. Contact the mother for verification.
• D. Escort the grandparent and newborn to the room.

Correct answer: B

Rationale: The correct action for the nurse to take is to respectfully deny the grandparent's request. In healthcare settings, strict security protocols are in place to ensure the safety of newborns. Only individuals with proper identification bracelets are allowed to transport newborns to prevent unauthorized individuals from taking them. Contacting the mother for verification would be time-consuming and may not be feasible immediately. Escorting the grandparent and newborn without proper identification would violate security protocols and compromise the newborn's safety. Notifying security should be done only if there is a threat or concern for safety, which is not the case in this scenario. Therefore, the best course of action is for the nurse to respectfully deny the grandparent's request to uphold the safety and security measures in place.

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