Nursing Elites

1. A nurse notices another nurse skipping hand hygiene. What is the appropriate course of action?

• A. Ignore the situation to maintain team harmony.
• B. Report the behavior to the supervisor.
• C. Discuss the issue with the nurse directly.
• D. Do nothing and continue with patient care.

Correct answer: B

Rationale: Correct hand hygiene is crucial for preventing the spread of infections and ensuring patient safety. When a nurse observes another healthcare worker skipping hand hygiene practices, it is essential to report this behavior to the supervisor. Reporting ensures that appropriate action is taken to address the issue and maintain a safe environment for patients. Ignoring the situation (Choice A) may compromise patient safety. Discussing the issue directly with the nurse (Choice C) may not always be effective in ensuring compliance. Doing nothing and continuing with patient care (Choice D) disregards the importance of infection control protocols.

2. A nurse provides instructions to a client about preventing injury while using crutches. What should the nurse tell the client to avoid?

• A. An abnormal stance
• B. Injury to the nerves
• C. A fall and further injury
• D. Skin breakdown

Correct answer: B

Rationale: The correct answer is B: Injury to the nerves. Resting the underside of the arm on the crutch pad can injure the nerves. Choice A, an abnormal stance, is not directly related to nerve injury while using crutches. Choice C, a fall and further injury, is a general risk associated with improper crutch use but does not specifically address nerve injury. Choice D, skin breakdown, is a concern related to pressure ulcers but not the primary focus when discussing injury prevention related to crutch use.

3. A nurse is assessing a client who is receiving a blood transfusion. Which of the following findings indicates the client might be experiencing an acute hemolytic reaction?

• A. Low back pain
• B. Distended neck veins
• C. Chills and fever
• D. Headache

Correct answer: C

Rationale: Chills and fever are classic signs of an acute hemolytic reaction, where the body is reacting to the transfused blood. This reaction can be life-threatening and requires immediate intervention. Low back pain, distended neck veins, and headache are not typical signs of an acute hemolytic reaction. Low back pain may be associated with kidney issues, distended neck veins with fluid overload or heart failure, and headache with various causes such as stress, dehydration, or migraines.

4. A nurse is assessing a client who has heart failure and is taking digoxin. The nurse should monitor the client for which of the following manifestations as an indication of digoxin toxicity to report to the provider?

• A. Diarrhea
• B. Vomiting
• C. Ringing in ears
• D. Dizziness

Correct answer: B

Rationale: The correct answer is B: Vomiting. Vomiting is a common sign of digoxin toxicity and should be reported to the healthcare provider. Diarrhea (Choice A) is a more common side effect of digoxin but not typically associated with toxicity. Ringing in the ears (Choice C) is a potential sign of toxicity; however, vomiting is a more immediate concern. Dizziness (Choice D) can occur with digoxin use but is not a specific indicator of toxicity.

5. A patient has just undergone a tracheostomy. What is the nurse's priority intervention?

• A. Suction the tracheostomy to maintain a patent airway.
• B. Administer pain medication as prescribed.
• C. Change the tracheostomy dressing every 4 hours.
• D. Monitor the patient's oxygen saturation closely.

Correct answer: A

Rationale: The correct answer is to suction the tracheostomy to maintain a patent airway. After a tracheostomy, the priority intervention is to ensure a clear airway to prevent respiratory distress. Administering pain medication, changing the tracheostomy dressing, and monitoring oxygen saturation are important but are secondary to maintaining a patent airway in a patient who has just undergone a tracheostomy.

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