Nursing Elites

1. Which of the following healthcare providers can legally have access to all, or part, of a patient's medical record because they have a 'need to know'? Select one that does not apply.

• A. Student nurses caring for a particular patient
• B. Registered nurses when they are not caring for a particular patient
• C. The Vice President for nursing who is investigating a patient fall
• D. Licensed practical nurses caring for a particular patient

Correct answer: B

Rationale: Student nurses, licensed practical nurses, the Vice President for nursing investigating a fall, and quality assurance nurses have a 'need to know' basis to access patient records. Registered nurses who are not directly involved in the care of a patient do not have a legitimate reason or 'need to know' to access that patient's medical records, making choice B the correct answer. The Vice President for nursing investigating a specific incident and licensed practical nurses directly involved in a patient's care have legitimate reasons to access the medical records, ensuring continuity and quality of care.

2. You are performing a neurological assessment of your adolescent patient. The patient has the Moro reflex. How should you interpret this neurological assessment finding?

• A. It is normal among adolescents.
• B. It indicates that the patient has an intact peripheral nervous system.
• C. It indicates that the patient has an intact central nervous system.
• D. It is not a normal finding.

Correct answer: D

Rationale: The Moro reflex, also known as the startle reflex, is typically present in infants up to around 4-6 months of age and is characterized by the infant's response to a sudden loss of support or loud noise. It is not a normal finding in adolescents or older individuals. Therefore, if an adolescent patient exhibits the Moro reflex during a neurological assessment, it is considered abnormal and warrants further evaluation. Choices A, B, and C are incorrect because the Moro reflex is not expected or normal among adolescents and does not specifically indicate the status of either the peripheral or central nervous system in this age group.

3. A nurse is assessing a client who has meningitis. Which of the following findings should the nurse report to the provider immediately?

• A. Generalized rash over trunk
• B. Increased temperature
• C. Decreased level of consciousness
• D. Report of photophobia

Correct answer: C

Rationale: The correct answer is C: Decreased level of consciousness. In a client with meningitis, a decreased level of consciousness is a critical finding that should be reported immediately. This could indicate increased intracranial pressure or neurological deterioration, requiring prompt intervention. Choices A, B, and D are important in the assessment of meningitis but are not as immediately concerning as a decreased level of consciousness. A generalized rash over the trunk can be seen in meningococcal meningitis, an increased temperature is expected due to the inflammatory response, and photophobia is a common symptom due to meningeal irritation.

4. Your patient has a blood potassium level of 9.2 mEq/L. What intervention should you anticipate for this patient?

• A. Intravenous potassium supplementation
• B. Intravenous calcium supplementation
• C. Kidney dialysis
• D. Parenteral nutrition

Correct answer: C

Rationale: The correct answer is C: Kidney dialysis. A blood potassium level of 9.2 mEq/L indicates severe hyperkalemia, which can be life-threatening. Kidney dialysis is the most appropriate intervention to rapidly lower potassium levels in this situation. Choice A, intravenous potassium supplementation, would worsen the hyperkalemia. Choice B, intravenous calcium supplementation, is not the primary intervention for hyperkalemia. Choice D, parenteral nutrition, is unrelated to treating hyperkalemia and would not address the immediate concern.

5. Who should document care?

• A. The LPNs should document the care that they provided and the care that was given by unlicensed assistive staff.
• B. The registered nurse must document all of the care that is provided by the nursing assistants because they are accountable for all care.
• C. All staff members should document all of the care that they have provided.
• D. All staff should document all of the care that they have provided but the registered nurse, as the only independent practitioner, signs it.

Correct answer: C

Rationale: All staff members should document the care they provided as part of their accountability and to ensure accurate and comprehensive records. In healthcare settings, it is essential for all staff to document the care they deliver for continuity of care and legal purposes. The registered nurse may sign off on the documentation for oversight purposes, but the responsibility of documenting care extends to all staff involved in patient care. Choices A and B incorrectly limit the responsibility to specific roles, while choice D inaccurately suggests that only the registered nurse signs off on the documentation, overlooking the importance of comprehensive documentation by all staff members involved.

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