Nursing Elites

1. The nurse uses prioritization to determine all of the following except:

• A. time allotment for certain tasks.
• B. appropriate interventions.
• C. treatment procedures.
• D. the need for client education.

Correct answer: C

Rationale: The correct answer is C: "treatment procedures." Prioritization in nursing involves determining the order of importance or urgency of tasks. Treatment procedures are standards of care that need to be followed as defined by the facility or nursing unit. They are not typically subject to prioritization but are mandatory based on established protocols. Time allotment for certain tasks, appropriate interventions, and the need for client education are all aspects that can be influenced by prioritization. For instance, prioritizing tasks helps in managing time effectively, selecting the most suitable interventions, and identifying the necessity for client education as part of the care plan.

2. A nurse planning care for her assigned clients understands that which aspect is the purpose of the hospital's standards of care?

• A. Identify methods of treatment.
• B. Provide direction for care based on the client's diagnosis.
• C. Identify new care methods based on current medical research.
• D. Provide direction for the practice of nursing

Correct answer: D

Rationale: The purpose of the hospital's standards of care is to provide a broad direction for the overall practice of nursing that applies to all nursing situations, across specialty areas, and across the country. These standards guide the practice of nursing by outlining the expected level of care and professional performance. While identifying methods of treatment is important, it is usually specific to individual client needs and not the overarching goal of standards of care. Providing direction for care solely based on the client's diagnosis is limited to a particular patient's treatment plan and does not encompass the broader scope of nursing practice. Identifying new care methods based on current medical research is essential for advancing healthcare practices but is not the primary purpose of the hospital's standards of care.

3. Following a recent tattoo, someone should be screened for:

• A. tuberculosis.
• B. herpes.
• C. hepatitis.
• D. syphilis.

Correct answer: C

Rationale: Following a recent tattoo, someone should be screened for hepatitis. Tattooing puts a client at risk for blood-borne hepatitis B or C if strict sterile procedures are not followed. Tuberculosis is an airborne pathogen, while herpes and syphilis are spread through direct contact like sexual activity. Therefore, hepatitis is the most relevant infection to screen for after getting a tattoo.

4. A nurse calls a health care provider to report that a client with congestive heart failure (CHF) is exhibiting dyspnea and worsening of wheezing. The health care provider, who is in a hurry because of a situation in the emergency department, gives the nurse a telephone prescription for furosemide (Lasix) but does not specify the route of administration. What is the appropriate action on the part of the nurse?

• A. Calling the health care provider who gave the telephone prescription to clarify the prescription
• B. Administering the medication orally and clarifying the prescription once the health care provider has finished caring for the client in the emergency department
• C. Calling the nursing supervisor for assistance in determining the route of administration
• D. Administering the medication intravenously because this route is generally used for clients with CHF

Correct answer: A

Rationale: Telephone prescriptions involve a health care provider dictating a prescribed therapy over the telephone to the nurse. The nurse must clarify the prescription by repeating it clearly and precisely to the health care provider. The nurse then writes the prescription on the health care provider's prescription sheet or enters it into the electronic medical record. It is crucial not to interpret an unclear prescription or administer a medication by a route that has not been expressly prescribed. In this case, the nurse should call the health care provider who gave the telephone prescription to clarify the prescription, ensuring the correct route of administration is specified. Options B, C, and D are incorrect because administering the medication without clarification, seeking assistance from the nursing supervisor, or choosing an arbitrary route of administration can compromise patient safety and violate medication administration protocols.

5. The nurse provides a postoperative client with an analgesic medication and darkens the room before the client goes to sleep for the night. The nurse's actions:

• A. help decrease stimuli from the cerebral cortex.
• B. stimulate hormonal changes in the brain.
• C. help the client's circadian rhythm.
• D. alert the hypothalamus in the brain.

Correct answer: A

Rationale: The nurse's actions of providing an analgesic medication and darkening the room aim to decrease stimuli from the cerebral cortex. Reduction of environmental stimuli, especially light and noise, from the cerebral cortex, which is an area of arousal, facilitates sleep. By decreasing input to this area, the client is more likely to fall asleep and stay asleep. Choices B, C, and D are incorrect because the scenario does not involve stimulating hormonal changes, influencing the circadian rhythm, or alerting the hypothalamus.

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