Nursing Elites

1. A nurse in charge of a long-term care facility who is working with a nursing assistant on the night shift prepares to take a break. To ensure client safety during the break, which actions should the nurse take? Select all that apply.

• A. Asking the nursing assistant to contact the health care provider during the nurse’s break if a client’s pain medication is not effective
• B. Informing the nursing assistant that she is leaving the nursing unit to get a cup of coffee from a vending machine in the lobby
• C. Asking the nursing assistant to administer a medication placed at the client's bedside if the client awakens
• D. Conducting client rounds before taking the break

Correct answer: D

Rationale: The nurse is responsible for ensuring client safety at all times and must not leave the nursing unit for any reason during the shift. The nurse’s break should be taken in a designated area located on the nursing unit. Before taking the break, the nurse should check all clients to ensure that they are safe and comfortable and that their needs have been met. Conducting client rounds before taking the break is crucial to assess the clients' conditions and address any immediate needs, ensuring their safety. Asking the nursing assistant to contact the health care provider during the nurse’s break is not appropriate as the nurse should handle this responsibility. Leaving the nursing unit to get coffee is not recommended as the nurse should stay within the unit to respond promptly to any client needs. Asking the nursing assistant to administer medication or make clinical decisions is outside the scope of their practice and should not be delegated.

2. What is the 24-hour day-night cycle known as?

• A. circadian rhythm
• B. infradian rhythm
• C. ultradian rhythm
• D. non-REM rhythm

Correct answer: A

Rationale: The correct answer is circadian rhythm. Circadian rhythm refers to the rhythmic repetition of patterns that occur approximately every 24 hours, regulating various biological processes related to the day-night cycle. Infradian rhythm, which is longer than 24 hours, and ultradian rhythm, which is shorter than 24 hours, are not the correct terms for the 24-hour cycle. Non-REM rhythm does not specifically relate to the 24-hour day-night cycle, making it an incorrect choice.

3. The nurse is educating a teenage female about preventing the transmission of genital herpes. Which of the following statements should the nurse include?

• A. "Do not sit on toilet seats without protection."?
• B. "Oral sex can transmit the virus."?
• C. "This infection can be transmitted via intercourse even when you do not feel ill."?
• D. "Try to drink plenty of fluids after sex to flush the reproductive tract."?

Correct answer: C

Rationale: Genital herpes can be transmitted through oral, genital, and anal sex. It is crucial to educate the patient that the infection can be transmitted via intercourse even when asymptomatic to prevent its spread. Choice A is incorrect as sitting on toilet seats without protection does not transmit genital herpes. Choice B is incorrect because oral sex can transmit the virus. Choice D is also incorrect as drinking fluids after sex does not prevent the transmission of genital herpes.

4. A client with cancer is transported to the radiology department for a bone scan to determine whether the cancer has metastasized to bone. While the client is in the radiology department, the client's wife arrives for a visit and asks what test is being performed on the client. What should the nurse tell the wife?

• A. A bone scan is being performed.
• B. She can read the client's medical record to determine what the health care provider prescribed.
• C. The radiology department is not clear as to which test has been prescribed.
• D. She will have to discuss the prescribed test with the client.

Correct answer: D

Rationale: In healthcare, confidentiality is crucial. Without the client's consent, nurses cannot disclose confidential information to anyone else, even to family members. Therefore, the appropriate response is to inform the client's wife that she will have to discuss the test with the client directly. It is not appropriate to disclose sensitive medical information without the client's permission. Offering the wife to read the medical record is a violation of privacy and confidentiality. Indicating that the radiology department is unclear about the prescribed test is inaccurate and does not uphold confidentiality. Moreover, it is not the responsibility of another department to disclose medical information; it is the duty of the healthcare provider and the client to discuss such matters.

5. The advanced directive in a client's chart is dated August 12, 1998. The client's daughter produces a Power of Attorney for Health Care, dated 2003, which contains different care directions. What should the nurse do?

• A. Follow the 1998 version because it's part of the legal chart.
• B. Follow the 1998 version because the physician's code order is based on it.
• C. Follow the 2003 version, place it in the chart, and communicate the update appropriately.
• D. Follow neither until clarified by the unit manager.

Correct answer: C

Rationale: The document dated 2003 supersedes the previous version and should be used as a basis for care directions. The nurse should follow the 2003 version, place it in the chart, and communicate the update appropriately to ensure that the most current care directions are followed. Choices A and B are incorrect because the 1998 version is now outdated, and the nurse should not rely on it for care decisions. Choice D is incorrect because the nurse should not delay following the updated document, and seeking clarification from the unit manager can lead to avoidable delays in care.

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