Nursing Elites

1. A patient with heart failure needs education on fluid restrictions. What is the most important information to provide?

• A. Monitor the patient's weight daily.
• B. Provide the patient with a fluid restriction plan.
• C. Instruct the patient to avoid salty foods.
• D. Encourage the patient to increase fluid intake.

Correct answer: B

Rationale: The most important information to provide to a patient with heart failure regarding fluid restrictions is to provide them with a fluid restriction plan. This plan helps the patient manage their fluid intake effectively, which is crucial in preventing complications associated with heart failure. Monitoring weight daily can be a part of the plan but is not the most important. Instructing the patient to avoid salty foods is beneficial but not as crucial as having a structured fluid restriction plan. Encouraging the patient to increase fluid intake would be counterproductive and potentially harmful in a patient with heart failure.

2. Which principle is most important for maintaining medical asepsis in a healthcare setting?

• A. Sterilize instruments only when visibly contaminated.
• B. Use sterile gloves for all patient interactions.
• C. Disinfect patient areas only at the end of the day.
• D. Clean hands thoroughly before and after patient contact.

Correct answer: D

Rationale: The correct answer is D: Clean hands thoroughly before and after patient contact. Hand hygiene is crucial for maintaining medical asepsis in a healthcare setting as it helps prevent the spread of infections between patients and healthcare workers. Choice A is incorrect because instruments should be sterilized regularly, not just when visibly contaminated. Choice B is incorrect as sterile gloves are not required for all patient interactions, only for specific procedures. Choice C is incorrect because patient areas should be disinfected regularly throughout the day, not just at the end of the day.

3. A charge nurse is discussing HIPAA with a newly licensed nurse. Which of the following actions should the charge nurse include in the teaching as an example of a HIPAA violation?

• A. Posting the name of the nurse providing care on a client's communication board
• B. Discussing the client's new medication with a hospital pharmacist
• C. Faxing requested medical information for a client who is transferring to another facility
• D. Emailing the client's positive hepatitis results from an unencrypted server

Correct answer: D

Rationale: The correct answer is D. Emailing client information through an unencrypted server is a HIPAA violation because it can lead to data breaches. Choices A, B, and C do not violate HIPAA. Posting the name of the nurse providing care on a client's communication board does not disclose sensitive health information. Discussing the client's new medication with a hospital pharmacist is a routine healthcare practice. Faxing requested medical information for a client who is transferring to another facility is a secure way to transmit healthcare data.

4. The client has a do-not-resuscitate (DNR) order. The family asks the nurse to ignore the DNR if the client codes. What is the nurse's responsibility?

• A. Follow the family's wishes
• B. Explain that the DNR must be honored
• C. Ignore the DNR and proceed with CPR
• D. Perform CPR if the client codes

Correct answer: B

Rationale: The correct answer is B: 'Explain that the DNR must be honored.' The nurse's responsibility is to follow the DNR order, as it is a legal and ethical obligation. Choice A is incorrect because following the family's wishes would go against the established DNR order. Choice C is incorrect as ignoring the DNR order is not appropriate. Choice D is also incorrect as performing CPR would be contrary to the client's expressed wishes in the DNR order.

5. In a disaster where a building has collapsed, which victim should a nurse attend to first?

• A. A victim who has died of multiple serious injuries
• B. A victim with a partial amputation of a leg who is bleeding profusely
• C. An alert victim who has numerous bruises on the arms and legs
• D. A hysterical victim who has sustained a head injury

Correct answer: B

Rationale: In a disaster situation like a building collapse, the nurse should attend to the victim with a partial amputation of a leg who is bleeding profusely first. This victim is at immediate risk of severe blood loss, which can be life-threatening. It is crucial to address life-threatening injuries like severe bleeding before attending to other less urgent cases. The victim with the amputation requires immediate intervention to control bleeding and stabilize their condition. Victims who are already deceased or have less urgent injuries can be attended to after addressing the critical cases.

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