Nursing Elites

1. How is the information documented on incident reports used?

• A. to analyze risk categories
• B. to ensure compliance with regulations
• C. to identify staff's educational needs
• D. all of the above

Correct answer: D

Rationale: The information documented on incident reports is used for various purposes, including analyzing risk categories, ensuring compliance with regulations, and identifying staff's educational needs. Incident reports provide valuable data that can be utilized in risk management, quality monitoring, and improvement programs. Therefore, the correct answer is 'all of the above.' Choices A, B, and C are all correct as incident reports are used for analyzing risk categories, ensuring compliance with regulations, and identifying staff's educational needs, respectively. Thus, the most comprehensive answer is 'all of the above.'

2. A nurse is planning the assignments for the shift. Which task should the nurse assign to the nursing assistant?

• A. Monitoring the vital signs for a client who needs a blood transfusion
• B. Performing hygiene for a client with diarrhea on whom contact precautions have been imposed
• C. Performing a dressing change on a client with a draining abdominal wound that requires frequent dressing changes
• D. Ambulating a client with angina who needs to be ambulated for the first time since admission

Correct answer: B

Rationale: When assigning tasks, a nurse should consider the job description of the nursing assistant, their clinical competence, and state law. Monitoring vital signs for a client needing a blood transfusion, performing a dressing change on a client with a draining wound, and ambulating a client with angina are tasks that require a licensed nurse's skill. On the other hand, providing hygiene care for a client with diarrhea under contact precautions is a task suitable for a nursing assistant. Nursing assistants are trained to provide hygiene care effectively and manage clients under specific precautions, making this task appropriate for them.

3. What should be the first action upon the discovery of an electrical fire?

• A. Disconnect the electrical power if it can be done safely
• B. Smother the source with an object like a blanket
• C. Saturate the source with water or another liquid
• D. Immediately activate the fire alarm

Correct answer: A

Rationale: The correct initial action upon discovering an electrical fire is to disconnect the electrical power if it can be done safely. This helps prevent the fire from spreading through the electrical system. Smothering the fire with a blanket is not recommended for electrical fires as it can fuel the fire. Saturating the source with water or other liquids is also not advised as it can lead to electric shock or spread the fire. Activating the fire alarm is important, but it should be done after disconnecting the power to prevent further escalation of the fire.

4. A child comes to the clinic with a skin rash. The maculopapular lesions are distributed around the mouth and have honey-colored drainage. The caregiver states that the rash is getting worse and seems to spread with the child's scratching. Which of the following advisory comments should be given?

• A. The history and presentation might indicate chickenpox, a highly contagious disease.
• B. The lesions might indicate a noncontagious infection that does not require isolation.
• C. The history and presentation might indicate an infectious illness called impetigo.
• D. The lesions are not contagious unless others have open wounds or lesions themselves.

Correct answer: C

Rationale: The scenario describes classic impetigo, which typically presents with maculopapular lesions around the mouth with honey-colored drainage, worsening with scratching. It is important to advise the caregiver that the history and presentation are indicative of impetigo, an infectious skin condition caused by bacteria. Treatment usually involves antibiotic therapy. Choice A is incorrect because chickenpox typically presents with a vesicular rash following a history of high fever. Choice B is incorrect as impetigo is contagious and requires precautions to prevent the spread of infection. Choice D is incorrect as impetigo is contagious irrespective of open wounds or lesions in others.

5. The nurse assesses a client for physiological risk factors for falls. The nurse should conclude that the client is not at risk if which of the following is discovered?

• A. history of dizziness
• B. need for a wheelchair due to reduced mobility
• C. weakness and fatigue noted when climbing stairs
• D. intact recent and remote memory

Correct answer: D

Rationale: The correct answer is intact recent and remote memory. Intact memory function indicates that the client is less likely to be at risk for falls as it suggests cognitive awareness and orientation, which are important for safety. Choices A, B, and C are risk factors for falls: a history of dizziness can lead to imbalance, the need for a wheelchair due to reduced mobility can increase fall risk, and weakness and fatigue when climbing stairs indicate physical limitations that predispose a client to falls. Therefore, these options would suggest an increased risk for falls.

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