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. The nurse should teach parents of small children that the most common type of first-degree burn is:

• A. scalding from hot bath water or spills.
• B. contact with hot surfaces such as stoves and fireplaces.
• C. contact with flammable liquids or gases resulting in flash burns.
• D. sunburn from lack of protection and overexposure.

Correct answer: D

Rationale: The correct answer is 'sunburn from lack of protection and overexposure.' First-degree burns primarily affect the outer layer of the skin and are commonly caused by overexposure to the sun without adequate protection, making it a significant concern for parents of small children. Choices A, B, and C describe other types of burns (scalding, contact with hot surfaces, and contact with flammable substances) that can cause more severe burns beyond the first-degree level. It is crucial for parents to be educated about sun safety measures to prevent sunburns in children.

3. A test that can correctly identify those who do not have a given disease is:

• A. specific.
• B. sensitive.
• C. negative culture
• D. marginal finding.

Correct answer: A

Rationale: The correct answer is 'specific.' Specificity refers to the ability of a test to correctly identify individuals who do not have a particular disease. In this case, when the client's lab culture report is negative for the suspected infection, a specific test would correctly identify that the client does not have the disease. 'Sensitive' (Choice B) is incorrect as sensitivity refers to the ability of a test to correctly identify individuals who do have the disease. 'Negative culture' (Choice C) is incorrect as it does not describe the test's ability but rather the result itself. 'Marginal finding' (Choice D) is irrelevant to the concept being tested in this question.

4. A client who has undergone a total hip replacement is told that she will need to go to an extended care rehabilitation facility for therapy before going home. Which member of the healthcare team should the nurse ask to plan the discharge and transition from the hospital to the rehabilitation facility?

• A. Physical therapist
• B. Occupational therapist
• C. Clergy
• D. Social worker

Correct answer: D

Rationale: In this scenario, the appropriate member of the healthcare team to plan the discharge and transition from the hospital to the rehabilitation facility is the social worker. Social workers are trained to provide counseling services, emotional support, arrange placements in care facilities, and locate financial resources for clients. While clergy provide spiritual support and guidance, physical therapists assist in physical treatments, and occupational therapists help with activities of daily living, the social worker is best suited to address the client's needs related to discharge planning and transition. Therefore, the correct answer is the social worker.

5. A safety measure to implement when transferring a client with hemiparesis from a bed to a wheelchair is:

• A. standing the client and walking him or her to the wheelchair.
• B. moving the wheelchair close to the client's bed and standing and pivoting the client on his unaffected extremity to the wheelchair.
• C. moving the wheelchair close to the client's bed and standing and pivoting the client on his affected extremity to the wheelchair.
• D. having the client stand and push his body to the wheelchair.

Correct answer: B

Rationale: When transferring a client with hemiparesis from a bed to a wheelchair, it is crucial to ensure their safety. The correct safety measure involves moving the wheelchair close to the client's bed and having the client stand and pivot on his unaffected extremity to the wheelchair. This method provides support with the unaffected limb, reducing the risk of falls and promoting a safer transfer. Choice A is incorrect because walking the client is unsafe and not recommended. Choice C is incorrect as pivoting the client on his affected extremity can lead to injury or falls due to weakness or lack of control. Choice D is incorrect as it puts the client at risk by requiring them to push their body, which may not be feasible or safe for someone with hemiparesis.

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