Nursing Elites

1. The home health nurse suspects elder abuse after observing fresh lacerations on the arms and legs of an older adult male client who lives with his daughter. Which action is most important for the nurse to take?

• A. Document the lacerations in the client's record
• B. Report findings to the supervisor for referral to adult protective services
• C. Ask the daughter who has been taking care of the client on a daily basis
• D. Apply dry dressings after cleansing the wounds

Correct answer: B

Rationale: In cases where elder abuse is suspected, the most critical action for the nurse to take is to report the findings to the supervisor for referral to adult protective services. This step is essential to protect the client from further harm and ensure their safety. Documenting the lacerations, as suggested in choice A, is important but not as urgent as ensuring immediate intervention by reporting the abuse. Asking the daughter for information, as in choice C, may not be effective if she is the abuser. Applying dressings, as in choice D, is a lower priority compared to taking action to address the suspected abuse.

2. While caring for a client with an AV fistula in the left forearm, the nurse observed a palpable buzzing sensation over the fistula. What action should the nurse take?

• A. Loosen the dressing of the fistula
• B. Report the presence of a bounding pulse
• C. Document that the fistula is intact
• D. Apply gentle pressure over the site

Correct answer: C

Rationale: The correct answer is C: Document that the fistula is intact. The palpable buzzing sensation (known as a thrill) over the AV fistula indicates proper functioning. It is essential for the nurse to document this finding to ensure ongoing monitoring of the fistula's status. Choices A, B, and D are incorrect. Choice A is incorrect because there is no indication to loosen the dressing. Choice B is incorrect as a bounding pulse is not associated with the palpable buzzing sensation of a thrill. Choice D is incorrect as applying pressure over the site is not necessary for this situation.

3. There has been a serious explosion at a local factory, and many of the injured are arriving at the hospital. Which of the following patients should a nurse attend to first?

• A. A 30-year-old male who is able to walk into the hospital on his own but has numerous lacerations on the chest and face
• B. A 45-year-old male who was brought in on a stretcher, has been assessed as having respiration and circulation within normal limits, and can follow simple commands
• C. A 50-year-old woman who can walk but has a broken arm and numerous lacerations
• D. A 19-year-old man who has numerous lacerations all over the body and whose respiration exceeds 30 breaths per minute

Correct answer: D

Rationale: The correct answer is D. The 19-year-old man with a respiration rate exceeding 30 breaths per minute is showing signs of respiratory distress, indicating a potentially life-threatening condition that requires immediate attention. Patients with respiratory distress should be prioritized as it is a critical condition. Choices A, B, and C describe patients with injuries that are less immediately life-threatening or who are more stable based on the provided information, so they can be attended to after the patient with respiratory distress. Therefore, the nurse should attend to the 19-year-old man first to address his respiratory distress and ensure his condition does not deteriorate further.

4. Based on the principle of asepsis, which situation should the nurse consider to be sterile?

• A. A one-inch border around the edges of a sterile field set up in the operating room
• B. A sterile glove that the nurse thinks might have touched her hair
• C. A wrapped, unopened sterile 4x4 gauze pad placed on a damp tabletop
• D. An open sterile Foley catheter kit set up on a table at the nurse's waist level

Correct answer: D

Rationale: The correct answer is D because an open sterile Foley catheter kit set up at waist level is considered sterile if it has not been contaminated. Choice A is incorrect because the one-inch border around a sterile field is considered non-sterile. Choice B is incorrect because a sterile glove that might have touched the nurse's hair is likely contaminated. Choice C is incorrect because a wrapped, unopened sterile gauze pad placed on a damp tabletop may have become contaminated.

5. Which of the following is a critical step in preventing ventilator-associated pneumonia (VAP)?

• A. Performing oral care with chlorhexidine
• B. Elevating the head of the bed to 30-45 degrees
• C. Administering prophylactic antibiotics
• D. Changing the ventilator circuit daily

Correct answer: B

Rationale: Elevating the head of the bed to 30-45 degrees is a critical step in preventing ventilator-associated pneumonia (VAP) because it helps reduce the risk of aspiration, which is a significant factor in the development of VAP. Elevating the head of the bed enhances pulmonary hygiene, decreases the risk of microaspiration, and promotes better lung function. Performing oral care with chlorhexidine is essential for oral hygiene but is not specifically aimed at preventing VAP. Administering prophylactic antibiotics without a clear indication can lead to antibiotic resistance and is not a recommended routine practice to prevent VAP. Changing the ventilator circuit daily is essential for infection control but is not the most critical step in preventing VAP.

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