Nursing Elites

1. By rolling contaminated gloves inside-out, the healthcare professional is affecting which step in the chain of infection?

• A. Mode of transmission
• B. Portal of entry
• C. Reservoir
• D. Portal of exit

Correct answer: A

Rationale: When contaminated gloves are rolled inside-out, they are serving as a mode of transmission by carrying pathogens from the reservoir's portal of exit to a new portal of entry. This action increases the risk of transmitting infections from one person to another, emphasizing the importance of proper glove removal techniques to prevent the spread of pathogens. Choices B, C, and D are incorrect in this context. Portal of entry refers to the route through which a pathogen enters a susceptible host, reservoir is the habitat where the pathogen lives, grows, and multiplies, and portal of exit is the path through which a pathogen leaves its host.

2. The nurse observes an unlicensed assistive personnel (UAP) taking a client's blood pressure with a cuff that is too small, but the blood pressure reading obtained is within the client's usual range. What action is most important for the nurse to implement?

• A. Tell the UAP to use a larger cuff at the next scheduled assessment.
• B. Reassess the client's blood pressure using a larger cuff.
• C. Have the unit educator review this procedure with the UAPs.
• D. Teach the UAP the correct technique for assessing blood pressure.

Correct answer: B

Rationale: The most important action is to ensure that an accurate BP reading is obtained. The nurse should reassess the blood pressure with the correct size cuff (B) to obtain an accurate reading. Postponing reassessment (A) could lead to inaccurate results. While (C and D) are important actions for education and quality improvement, they are not as critical as obtaining an accurate blood pressure reading in this situation.

3. The nurse plans to assist a male client out of bed for the first time since his surgery yesterday. His wife objects and tells the nurse to get out of the room because her husband is too ill to get out of bed. What should the nurse do first?

• A. Administer nasal oxygen at a rate of 5 L/min
• B. Help the client to lie back down in the bed
• C. Quickly pivot the client to the chair and elevate the legs
• D. Check the client’s blood pressure and pulse

Correct answer: D

Rationale: Before assisting the client out of bed, the nurse should first assess the client's blood pressure and pulse. This assessment is crucial to determine the client's physiological stability and readiness for ambulation. It ensures the client's safety during the transfer and helps prevent any potential complications that may arise from getting out of bed. Administering oxygen, lying the client back down, or quickly moving the client to a chair without assessing vital signs can compromise the client's safety and may lead to adverse outcomes.

4. What is the most important action for the nurse to take when caring for a client with a spinal cord injury experiencing autonomic dysreflexia?

• A. Elevate the head of the bed to 45 degrees.
• B. Monitor the client's respiratory rate.
• C. Administer an antihypertensive medication.
• D. Assess the client's blood glucose level.

Correct answer: A

Rationale: In a client with autonomic dysreflexia, the most critical action is to elevate the head of the bed to 45 degrees (A). This positioning helps reduce blood pressure, which is essential in managing autonomic dysreflexia. Monitoring the client's respiratory rate (B) is important for overall assessment but not the priority in this situation. Administering an antihypertensive medication (C) without addressing the positioning issue first can lead to further complications. Assessing the client's blood glucose level (D) is not directly related to autonomic dysreflexia and is not the initial priority in this scenario.

5. The nurse-manager of a skilled nursing (chronic care) unit is instructing UAPs on ways to prevent complications of immobility. Which intervention should be included in this instruction?

• A. Perform range-of-motion exercises to prevent contractures.
• B. Decrease the client's fluid intake to prevent diarrhea.
• C. Massage the client's legs to reduce the occurrence of embolisms.
• D. Turn the client from side to back every shift.

Correct answer: A

Rationale: Performing range-of-motion exercises is essential in preventing contractures, which are common complications of immobility. These exercises help maintain joint flexibility and muscle strength, reducing the risk of contractures that can lead to functional limitations or pain for the client. Choices B, C, and D are incorrect. Decreasing fluid intake does not prevent immobility complications, but it can lead to dehydration. Massaging the client's legs does not directly address the prevention of immobility complications like contractures. Turning the client from side to back every shift is important for preventing pressure ulcers but does not directly address complications of immobility like contractures.

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