Nursing Elites

1. The nurse is caring for a patient who is at risk for infection. Which action by the nurse indicates correct understanding about standard precautions?

• A. Teaches the patient about good nutrition.
• B. Disposes of an uncapped needle in the designated container.
• C. Wears eyewear when emptying the urinary drainage bag.
• D. Dons gloves when wearing artificial nails.

Correct answer: C

Rationale: The correct understanding of standard precautions includes wearing appropriate personal protective equipment to prevent exposure to body fluids. Wearing eyewear when emptying the urinary drainage bag is crucial as it protects the nurse's eyes from potential splashes of body fluids. Teaching the patient about good nutrition (Choice A) is important for overall health but is not directly related to standard precautions. Disposing of an uncapped needle correctly (Choice B) is part of safe needle handling but does not specifically relate to standard precautions. Donning gloves when wearing artificial nails (Choice D) is not a correct understanding of standard precautions, as artificial nails can harbor microorganisms and increase the risk of infection transmission.

2. The nurse is assessing the patient for respiratory complications of immobility. What action should the nurse take?

• A. Auscultate the entire lung region to assess lung sounds.
• B. Assess the patient at least every 4 hours.
• C. Focus auscultation on the upper lung fields.
• D. Inspect chest wall movements primarily during the expiratory cycle.

Correct answer: A

Rationale: Auscultating the entire lung region is the most appropriate action when assessing a patient for respiratory complications related to immobility. This approach helps the nurse identify any abnormalities in lung sounds, such as diminished breath sounds or the presence of secretions. Assessing the patient at regular intervals (choice B) is important but does not specifically address the respiratory assessment needed in this situation. Focusing auscultation on the upper lung fields (choice C) may miss potential issues in other areas. Inspecting chest wall movements primarily during the expiratory cycle (choice D) is not the most effective way to assess lung sounds and identify respiratory complications.

3. What are the nursing interventions for a patient with acute kidney injury (AKI)?

• A. Preparing the patient for dialysis if necessary
• B. Providing dietary modifications to reduce potassium
• C. Monitoring urine output and electrolytes
• D. Administering fluids and monitoring blood pressure

Correct answer: A

Rationale: The correct nursing intervention for a patient with acute kidney injury (AKI) includes preparing the patient for dialysis if necessary. While choices B, C, and D are also important aspects of managing AKI, the critical intervention in severe cases is to prepare the patient for dialysis to support kidney function. Providing dietary modifications to reduce potassium, monitoring urine output and electrolytes, and administering fluids are essential components of the overall care plan for AKI patients, but in cases where the condition is severe or if conservative management fails, dialysis may be required to support the patient's kidney function and prevent further complications.

4. Which of the following actions is a means of maintaining medical asepsis to reduce and prevent the spread of microorganisms?

• A. Sterilizing contaminated items
• B. Routinely cleaning the hospital environment
• C. Reapplying a sterile dressing
• D. Applying a sterile gown and gloves

Correct answer: A

Rationale: The correct answer is A: Sterilizing contaminated items. Maintaining medical asepsis involves ensuring that items are free of microorganisms to prevent infections. Sterilizing contaminated items is a crucial step in this process as it eliminates all microorganisms, including spores. Choices B, C, and D do not directly address the process of reducing and preventing the spread of microorganisms. While routinely cleaning the hospital environment is important for cleanliness, it does not guarantee the elimination of all microorganisms. Reapplying a sterile dressing and applying a sterile gown and gloves are specific actions related to personal protective equipment and wound care, not the general maintenance of medical asepsis.

5. Which patient should the nurse see first?

• A. A 1-month-old infant looking at a shiny, round battery just out of arm's reach.
• B. A 56-year-old patient with oxygen and a lighter on the bedside table.
• C. A 56-year-old patient with oxygen using an electric razor for grooming.
• D. A bedridden patient who has a reddened area on the buttocks and needs to be turned.

Correct answer: B

Rationale: The correct answer is B because the patient with oxygen and a lighter on the bedside table is at immediate risk of fire. Oxygen promotes combustion, and having a lighter nearby poses a serious safety hazard. This situation requires urgent attention to prevent a potential disaster. Choices A, C, and D do not present immediate life-threatening risks compared to the patient with oxygen and a lighter nearby.

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