Nursing Elites

1. Earlier this morning, an elderly Hispanic female was discharged to a LTC facility. The family members are now gathered in the hallway outside her room. What is the best action?

• A. Ask the family to wait in the cafeteria while the next of kin makes the necessary arrangements
• B. Provide space and privacy for the family to share their concerns about the client’s discharge
• C. Ask the social worker to encourage the family to clear the hallway
• D. Explain to the family the client’s need for privacy so that she can make independent decisions

Correct answer: B

Rationale: In this situation, providing space and privacy for the family allows them to openly discuss their concerns regarding the client’s discharge. It respects the family's need for support, communication, and involvement in the decision-making process, ultimately fostering a more effective and compassionate care environment.

2. A client is admitted with a diagnosis of right-sided heart failure. What assessment finding should the nurse anticipate?

• A. Jugular vein distention.
• B. Crackles in the lungs.
• C. Peripheral edema.
• D. Hepatomegaly.

Correct answer: C

Rationale: In right-sided heart failure, the heart's inability to effectively pump blood to the lungs leads to fluid backup in the systemic circulation, resulting in peripheral edema (swelling in lower extremities). While jugular vein distention (A) and hepatomegaly (D) can also occur in right-sided heart failure, peripheral edema is a hallmark sign due to fluid retention. Crackles in the lungs (B) are more commonly associated with left-sided heart failure, where fluid accumulates in the lungs.

3. When performing sterile wound care in the acute care setting, the nurse obtains a bottle of normal saline from the bedside table that is labeled 'opened' and dated 48 hours prior to the current date. Which is the best action for the nurse to take?

• A. Use the normal saline solution once more and then discard.
• B. Obtain a new sterile syringe to draw up the labeled saline solution.
• C. Use the saline solution and then relabel the bottle with the current date.
• D. Discard the saline solution and obtain a new unopened bottle.

Correct answer: D

Rationale: When performing sterile wound care, it is essential to use only newly opened and unexpired solutions to maintain sterility and prevent infections. The normal saline solution obtained by the nurse is labeled 'opened' and dated 48 hours prior to the current date, making it no longer considered sterile. The best action for the nurse to take in this situation is to discard the saline solution and obtain a new unopened bottle to ensure the safety and effectiveness of wound care. Choices A, B, and C are incorrect because reusing an already opened and outdated solution or attempting to relabel it with a current date can compromise patient safety and increase the risk of infection.

4. When is the first dose of Hepatitis B vaccine typically administered?

• A. In the hospital at birth
• B. At one year old
• C. At six months
• D. At 18 months

Correct answer: A

Rationale: The first dose of the Hepatitis B vaccine is usually administered at birth in the hospital to provide early protection against the virus. Giving the vaccine at birth helps prevent perinatal transmission of Hepatitis B from an infected mother to her newborn. This early administration is crucial in establishing immunity in infants, as delaying the vaccine increases the risk of infection. Options B, C, and D are incorrect because delaying the administration of the Hepatitis B vaccine can leave infants vulnerable to the virus during the critical early months of life when they are most susceptible.

5. A client with a history of myocardial infarction (MI) is admitted with chest pain. Which laboratory test should the nurse expect to be ordered to determine if the client is experiencing another MI?

• A. Troponin
• B. Myoglobin
• C. CK-MB
• D. C-reactive protein

Correct answer: A

Rationale: Troponin is the most specific and sensitive laboratory test for detecting myocardial infarction (MI). It is released when there is damage to the heart muscle, making it a valuable marker for diagnosing another MI. Myoglobin and CK-MB can also be elevated in MI, but troponin is preferred due to its higher specificity. C-reactive protein is a marker of inflammation and not specific to MI.

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