Nursing Elites

1. Examples of patients suffering from impaired awareness include all of the following except:

• A. A semiconscious or overfatigued patient
• B. A disoriented or confused patient
• C. A patient who cannot care for themselves at home
• D. A patient demonstrating symptoms of drug or alcohol withdrawal

Correct answer: C

Rationale: Patients with impaired awareness may exhibit symptoms such as being semiconscious, overfatigued, disoriented, confused, or demonstrating symptoms of drug or alcohol withdrawal. A patient who cannot care for themselves at home does not necessarily indicate impaired awareness, as this could be due to physical limitations or lack of support, rather than a cognitive deficit.

2. When preparing to administer an IM injection that is irritating to the subcutaneous tissue, what is the best action to prevent tracking of the medication?

• A. Use a small gauge needle
• B. Apply ice on the injection site
• C. Administer at a 45° angle
• D. Use the Z-track technique

Correct answer: D

Rationale: The Z-track technique is the best action to prevent tracking of the medication when administering an IM injection that is irritating to the subcutaneous tissue. This technique involves pulling the skin to the side before administering the injection and then releasing the skin after the injection. By doing so, a zig-zag pathway is created, preventing the medication from leaking into the subcutaneous tissue and reducing irritation. Options A, B, and C are incorrect. Using a small gauge needle may not prevent tracking of the medication. Applying ice on the injection site or administering at a 45° angle does not specifically address preventing tracking of the medication in cases where the injection is irritating to the subcutaneous tissue.

3. A charge nurse is recommending postpartum client discharge following a local disaster. Which of the following should the nurse recommend for discharge?

• A. A 42-year-old client who has preeclampsia and a BP of 166/110 mm Hg
• B. A 15-year-old client who delivered via emergency cesarean birth 1 day ago
• C. A client who received 2 units of packed RBCs 6 hr ago for a postpartum hemorrhage
• D. A client who delivered precipitously 36 hr ago and has a second-degree perineal laceration

Correct answer: D

Rationale: The most appropriate client to recommend for discharge following a local disaster in the postpartum unit is the one who delivered precipitously 36 hours ago and has a second-degree perineal laceration. This client's condition is stable enough for discharge, and the timing and extent of the perineal laceration are within expectations for a safe discharge. Clients with conditions such as preeclampsia, recent emergency cesarean birth, or recent administration of packed RBCs for postpartum hemorrhage require further monitoring and care before being considered for discharge.

4. The physician orders a platelet count to be performed on Mrs. Smith after breakfast. The nurse is responsible for:

• A. Instructing the patient about this diagnostic test
• B. Writing the order for this test
• C. Giving the patient breakfast
• D. All of the above

Correct answer: A

Rationale: The nurse's responsibility in this scenario is to instruct the patient about the diagnostic test ordered by the physician. This includes explaining the purpose of the test, any necessary preparations, and what to expect. The nurse is not responsible for writing the order, as this is the physician's role. Additionally, providing breakfast is not directly related to the platelet count test. Therefore, the correct answer is A, which aligns with the nurse's role in educating and supporting the patient regarding the test.

5. What is the primary goal of performing a bed bath?

• A. To cleanse, refresh, and provide comfort to the client who must remain in bed
• B. To expose the necessary parts of the body
• C. To develop skills in bed bath
• D. To check the body temperature of the client in bed

Correct answer: A

Rationale: The primary goal of performing a bed bath is to cleanse, refresh, and provide comfort to clients who are unable to leave their bed. This helps maintain their hygiene, promotes skin health, and enhances their overall well-being. Choice B is incorrect as the primary purpose is not to expose body parts but to provide hygiene and comfort. Choice C is incorrect as the main goal is client care, not skill development. Choice D is incorrect as checking body temperature is not the main purpose of a bed bath.

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