Nursing Elites

1. The charge nurse has a health care team that consists of 1 PN, 1 unlicensed assistive personnel (UAP), and 1 PN nursing student. Which assignment should be questioned by the nurse manager?

• A. An admission at the change of shifts with atrial fibrillation and heart failure - PN
• B. Client who had a major stroke 6 days ago - PN nursing student
• C. A child with burns who has packed cells and albumin IV running - charge nurse
• D. An elderly client who had a myocardial infarction a week ago - UAP

Correct answer: A

Rationale: Assigning an admission with atrial fibrillation and heart failure to a PN is not appropriate. This complex case requires more advanced skills and should not be managed by a PN without adequate support. The PN may not have the necessary training or expertise to handle such a critical situation effectively. Choice B is a suitable assignment for a PN nursing student as they can handle a client who had a major stroke 6 days ago. Choice C is also appropriate as a child with burns receiving packed cells and albumin IV running can be managed by the charge nurse. Choice D is within the scope of practice for a UAP since an elderly client post-myocardial infarction a week ago may require basic care and assistance.

2. The healthcare provider is caring for a patient with a spinal cord injury and notices that the patient's hips have a tendency to rotate externally when the patient is supine. Which device will the healthcare provider use to help prevent injury secondary to this rotation?

• A. Hand rolls
• B. A trapeze bar
• C. A trochanter roll
• D. Hand-wrist splints

Correct answer: C

Rationale: A trochanter roll is the correct choice as it is used to prevent external rotation of the hips when the patient is in a supine position. Hand rolls (Choice A) are incorrect because they are used to prevent contractures of the fingers, wrist, and hand. A trapeze bar (Choice B) is not the correct option as it helps patients change positions in bed and aids with movement, not specifically for hip rotation. Hand-wrist splints (Choice D) are also incorrect as they are used to maintain the functional position of the wrist and hand, not to address hip rotation.

3. During auscultation of the anterior chest wall of a client newly admitted to a medical-surgical unit, what type of breath sounds should a nurse expect to hear?

• A. Normal breath sounds
• B. Adventitious breath sounds
• C. Absent breath sounds
• D. Diminished breath sounds

Correct answer: A

Rationale: During auscultation of the chest, normal breath sounds are the expected findings in a client who is newly admitted without respiratory complaints. Normal breath sounds indicate proper airflow through the airways without any abnormalities. Adventitious breath sounds (Choice B) refer to abnormal lung sounds such as crackles or wheezes, which are indicative of underlying respiratory issues. Absent breath sounds (Choice C) suggest a lack of airflow to a particular lung area, which could be due to conditions like pneumothorax. Diminished breath sounds (Choice D) indicate reduced airflow or consolidation in a specific lung region, often seen in conditions like pleural effusion or pneumonia. Therefore, in a newly admitted client without respiratory complaints, the nurse should expect to hear normal breath sounds during auscultation.

4. A nurse is providing teaching to a newly licensed nurse about the care of a client who has MRSA. Which of the following statements by the newly licensed nurse indicates an understanding of teaching?

• A. I will place the client in a private room
• B. I will tell the client’s visitors to wear a mask when they are within 3 feet of the client
• C. I will remove my gown after leaving the client’s room
• D. I will wear an N95 respirator mask when caring for the client

Correct answer: A

Rationale: The correct answer is A: 'I will place the client in a private room.' Placing the client in a private room helps prevent the spread of MRSA, a contact precaution. Choice B is incorrect because visitors should be following standard precautions for MRSA, not just wearing a mask within a specific distance. Choice C is incorrect as the gown should be removed before exiting the client's room to prevent the spread of MRSA. Choice D is incorrect as an N95 respirator mask is not typically required for the care of a client with MRSA; standard precautions are usually sufficient.

5. While being prepared for transport to the operating room, a client scheduled for hysterectomy informs the nurse that she no longer wants to have surgery. What action should the nurse take?

• A. Notify the provider about the client's decision
• B. Proceed with the transport
• C. Prepare the surgical site
• D. Document the client’s statement

Correct answer: A

Rationale: The correct action for the nurse to take in this situation is to notify the provider about the client's decision. By informing the provider, they can discuss the client's change in decision, explore the reasons behind it, and determine the appropriate course of action. Proceeding with the transport (Choice B) without addressing the client's concerns would not respect the client's autonomy and right to make decisions about their own healthcare. Preparing the surgical site (Choice C) would be premature and inappropriate if the client no longer wishes to proceed with the surgery. While documenting the client's statement (Choice D) is important for documentation purposes, the immediate priority is to involve the provider in the decision-making process.

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