Nursing Elites

1. A patient presents with an exacerbation of chronic obstructive pulmonary disease (COPD) characterized by shortness of breath, orthopnea, thick, tenacious secretions, and a dry hacking cough. An appropriate nursing diagnosis would be:

• A. Ineffective airway clearance related to thick, tenacious secretions.
• B. Ineffective airway clearance related to dry, hacking cough.
• C. Ineffective individual coping with COPD.
• D. Pain related to immobilization of affected leg.

Correct answer: A

Rationale: The patient's symptoms of shortness of breath, orthopnea, thick, tenacious secretions, and a dry hacking cough all point towards a potential airway clearance issue. This makes option A, 'Ineffective airway clearance related to thick, tenacious secretions,' the most appropriate nursing diagnosis. It directly addresses the thick secretions and suggests a potential cause of the breathing difficulty the patient is experiencing.

2. During a seizure, what is the primary intervention?

• A. Protect the patient from injury
• B. Insert an airway
• C. Elevate the head of the bed
• D. Withdraw all pain medications

Correct answer: A

Rationale: The primary intervention during a seizure is to protect the patient from injury. This involves creating a safe environment by moving harmful objects away, cushioning the head, and staying with the patient until the seizure ends. Inserting an airway is only necessary if the patient's airway is obstructed, not routinely during a seizure. Elevating the head of the bed is not a priority during an active seizure as it won't affect the seizure's outcome. Withdrawing all pain medications is not a standard practice unless there are specific contraindications related to the seizure itself.

3. What is required for effective hand washing?

• A. Soap or detergent to promote emulsification
• B. Hot water to destroy bacteria
• C. A disinfectant to increase surface tension
• D. All of the above

Correct answer: A

Rationale: To effectively wash hands, soap or detergent is essential as they help emulsify fats and oils, allowing them to be rinsed away. Hot water alone cannot effectively destroy bacteria, and a disinfectant is not typically required for routine hand washing.

4. What term is used to describe the process of preparing the bed with a new set of linens?

• A. Bed bath
• B. Bed making
• C. Bed shampoo
• D. Bed lining

Correct answer: B

Rationale: The correct answer is 'Bed making.' Bed making is the term used to describe the process of preparing the bed with a new set of linens. This includes changing the sheets, pillowcases, and adding any additional bedding to make the bed clean, fresh, and comfortable for the next use. 'Bed bath' is typically associated with washing a patient in bed, 'Bed shampoo' is not a common term related to bed preparation, and 'Bed lining' does not accurately describe the process of changing linens on a bed.

5. A new head nurse on a unit is distressed about the poor staffing on the 11 p.m. to 7 a.m. shift. What should she do?

• A. Complain to her fellow nurses
• B. Wait until she knows more about the unit
• C. Discuss the problem with her supervisor
• D. Inform the staff that they must volunteer to rotate

Correct answer: C

Rationale: In this scenario, the new head nurse should discuss the problem with her supervisor. This is the most appropriate action as the supervisor is in a position to address staffing concerns effectively and make necessary changes. Complaining to fellow nurses may not lead to a solution, waiting may exacerbate the issue, and demanding staff rotation without proper discussion is not a collaborative approach to resolving the problem.

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