Nursing Elites

1. A nursing instructor asks a nursing student to describe accountability. Which statement(s) by the student indicate(s) an accurate description of accountability?

• A. Check the unit policy for the protocol for the care of clients who have been sexually assaulted.
• B. Ask a medical assistant.
• C. Call the nurse in charge of the day shift.
• D. Ask the police officers who brought the client to the center.

Correct answer: A

Rationale: Accountability in nursing involves taking responsibility for one's actions and decisions. In this scenario, checking the unit policy for the protocol related to the care of sexually assaulted clients demonstrates accountability. Policies and protocols provide guidance on appropriate actions and responsibilities in specific situations. Asking a medical assistant, calling the day shift nurse in charge, or consulting police officers are not appropriate actions to demonstrate accountability in this context. Seeking further clarification from the agency nursing supervisor on the night shift after reviewing the policy or protocol would be a more suitable course of action.

2. When making an occupied bed, what is important for the nurse to do?

• A. keep the bed in the low position.
• B. use a bath blanket or top sheet for warmth and privacy
• C. constantly keep side rails raised on both sides.
• D. move back and forth from one side to the other when adjusting the linens.

Correct answer: B

Rationale: When making an occupied bed, using a bath blanket or top sheet is important as it keeps the client warm and provides privacy, ensuring their comfort and dignity. Keeping the bed in the low position is crucial for the safety of the client, preventing falls and injuries. Constantly keeping side rails raised on both sides is unnecessary and may restrict the client's movement unnecessarily. Moving back and forth from one side to the other when adjusting the linens is inefficient and disrupts the workflow; it is more effective to work systematically from one side to the other to ensure proper bed-making.

3. A nurse in a medical-surgical unit overhears the nursing staff openly discussing a client and stating that the client is uncooperative and a real pain to care for. The nurse would most appropriately manage this issue by taking which action?

• A. Leaving articles about judgmental opinions in the nurses' report room
• B. Reporting the nurses' comments to administration
• C. Discouraging the judgmental comments
• D. Ignoring the comments made about the client

Correct answer: C

Rationale: Nurses must discuss clients in a professional manner and avoid using judgmental language such as 'uncooperative' or 'difficult.' When such comments and language are discouraged, fewer comments will be made. Ignoring the comments is an inappropriate option because the concern will not be addressed. Leaving articles about judgmental opinions in the nurses' report room indirectly addresses the issue, but there is no guarantee that the staff will read them. Reporting the nurses' comments to administration does not directly address the issue. The best approach for the nurse is to discourage judgmental comments directly with the staff members. Since this action is not provided in the options, discouraging judgmental comments is the most appropriate way to manage this concern.

4. Which of the following might be an appropriate nursing diagnosis for an epileptic client?

• A. Dysreflexia
• B. Risk for Injury
• C. Urinary Retention
• D. Unbalanced Nutrition

Correct answer: B

Rationale: The correct nursing diagnosis for an epileptic client would be 'Risk for Injury' as the client is prone to injuries during seizure activity, such as head trauma from falls. Epilepsy does not typically cause dysreflexia. While urinary retention may occur during or after a seizure, it is not a common nursing diagnosis related to epilepsy. 'Unbalanced Nutrition' is not a priority nursing diagnosis for an epileptic client compared to the immediate risk of injury during seizures.

5. An example of a process standard on a med-surg unit is:

• A. a procedure for changing IV tubing.
• B. a policy for staffing.
• C. the job description of the CEO (chief executive officer).
• D. a procedure for checking waveforms on a client being treated with an intra-aortic balloon pump.

Correct answer: D

Rationale: Process standards define the actions and behaviors required by staff to provide care on a med-surg unit. A procedure for changing IV tubing is a critical psychomotor skill necessary for safe and effective patient care in this setting. Choice B, a policy for staffing, pertains more to organizational management rather than specific care processes on the unit. Choice C, the job description of the CEO, delineates the responsibilities of the organization's top executive and is not a process standard for frontline staff. Choice D, a procedure for checking waveforms on a client with an intra-aortic balloon pump, is more specific to a cardiac care unit and not typically performed on a med-surg unit.

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