Nursing Elites

1. A healthcare professional is supervising the logrolling of a patient. To which patient is the healthcare professional most likely providing care?

• A. A patient with neck surgery
• B. A patient with hypostatic pneumonia
• C. A patient with a total knee replacement
• D. A patient with a stage IV pressure ulcer

Correct answer: A

Rationale: Logrolling is a technique used to move a patient as a single unit to prevent twisting or bending of the spine. Patients who have undergone neck surgery require special care to ensure the spinal column remains in straight alignment to prevent further injury. Therefore, the correct answer is a patient with neck surgery. Choice B, a patient with hypostatic pneumonia, does not require logrolling, as it is a condition affecting the lungs, not the spine. Choice C, a patient with a total knee replacement, does not typically necessitate logrolling, as the procedure focuses on the knee joint, not the spine. Choice D, a patient with a stage IV pressure ulcer, requires wound care but does not necessarily involve logrolling unless the ulcer is located in a critical area that requires special handling.

2. A policy requiring the removal of acrylic nails by all nursing personnel was implemented 6 months ago. Which assessment measure best determines if the intended outcome of the policy is being achieved?

• A. Number of staff-induced injuries
• B. Client satisfaction survey
• C. Healthcare-associated infection rate
• D. Rate of needle-stick injuries by nurses

Correct answer: C

Rationale: The correct answer is C: Healthcare-associated infection rate. This measure best indicates the effect of the policy on infection control. By monitoring the healthcare-associated infection rate, it can be determined if the policy of removing acrylic nails has contributed to reducing the risk of infections. Choices A, B, and D are not as directly linked to the outcome of the policy. The number of staff-induced injuries may not be solely due to acrylic nails. Client satisfaction may not be directly impacted by this policy, and needle-stick injuries are more related to a different aspect of healthcare practice.

3. When entering the room of an adult male, the nurse finds that the client is very anxious. Before providing care, what action should the nurse take?

• A. Divert the client’s attention
• B. Call for additional help from staff
• C. Document the planned action
• D. Re-assess the client's situation

Correct answer: D

Rationale: Re-assessing the client's situation before providing care is the most appropriate action in this scenario. By re-evaluating the client, the nurse can better understand the cause of the anxiety and tailor the care accordingly. Diverting the client's attention (Choice A) may not address the underlying issue causing anxiety. Calling for additional help (Choice B) is not the initial step required unless there is an urgent need. Documenting the planned action (Choice C) should come after reassessing the client to ensure accuracy and relevance.

4. A nurse in a provider's office is obtaining the health and medication history of a client who has a respiratory infection. The client tells the nurse that she is not aware of any allergies, but that she did develop a rash the last time she was taking an antibiotic. Which of the following information should the nurse give the client?

• A. "Rashes are very common, especially if you have dry skin. Did it go away on its own?"
• B. "Virtually all medications have adverse effects. It sounds like this could have been an adverse effect of the antibiotic."
• C. "It's unlikely that your doctor will prescribe an antibiotic for what seems to be a minor viral infection, so we shouldn't be concerned about that rash."
• D. "We need to document the exact medication you were taking because you might be allergic to it."

Correct answer: D

Rationale: The correct answer is D. If a client reports developing a rash when taking a specific medication, even if they are not aware of any allergies, it is crucial to document this information. This is necessary to prevent future allergic reactions. Identifying the exact medication that caused the rash is essential as the client could have an allergy to it. Providing this information allows healthcare providers to avoid prescribing the same medication again, which could potentially lead to more severe allergic reactions or life-threatening situations. Choices A, B, and C are incorrect because they do not address the importance of documenting the specific medication that caused the adverse reaction or the potential risks of repeating the medication. Simply attributing the rash to common occurrences, adverse effects of medications in general, or assuming the rash is insignificant in the current context can overlook the critical aspect of identifying and avoiding allergens.

5. A client with Guillain-Barre syndrome is in a non-responsive state, yet vital signs are stable and breathing is independent. What should the nurse document to most accurately describe the client's condition?

• A. Comatose, breathing unlabored
• B. Glasgow Coma Scale 8, respirations regular
• C. Appears to be sleeping, vital signs stable
• D. Glasgow Coma Scale 13, no ventilator required

Correct answer: B

Rationale: The correct answer is B: 'Glasgow Coma Scale 8, respirations regular.' A Glasgow Coma Scale of 8 with regular respirations accurately describes a non-responsive state with independent breathing. Choice A is incorrect because 'comatose' implies a deep state of unconsciousness, which may not be accurate in this case. Choice C is incorrect as stating the client 'appears to be sleeping' may not accurately reflect the severity of the situation. Choice D is incorrect because a Glasgow Coma Scale of 13 would not typically correspond to a non-responsive state.

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