Nursing Elites

1. What is the primary purpose of handwashing?

• A. To promote hand circulation
• B. To prevent the transfer of microorganisms
• C. To avoid touching the client with a dirty hand
• D. To provide comfort

Correct answer: B

Rationale: The primary purpose of handwashing is to prevent the transfer of microorganisms. Proper hand hygiene helps reduce the risk of spreading harmful bacteria and viruses, thus promoting overall health and preventing infections. Choice A is incorrect as handwashing primarily focuses on cleanliness rather than promoting circulation. Choice C is incorrect as it implies that the main concern is avoiding client discomfort rather than preventing infection. Choice D is incorrect as while handwashing can be comforting in some situations, its primary purpose is not to provide comfort but to maintain hygiene.

2. Which hormone is secreted by the Islets of Langerhans?

• A. Progesterone
• B. Testosterone
• C. Insulin
• D. Hemoglobin

Correct answer: C

Rationale: Insulin is the correct answer. It is the hormone secreted by the Islets of Langerhans in the pancreas. These specialized cells regulate blood sugar levels by releasing insulin in response to high blood glucose levels. Insulin aids in glucose absorption by cells, lowering blood sugar levels. Progesterone, testosterone, and hemoglobin are not secreted by the Islets of Langerhans and do not play a role in blood sugar regulation.

3. The physician orders a maintenance dose of 5,000 units of subcutaneous heparin (an anticoagulant) daily. Nursing responsibilities for Mrs. Mitchell now include:

• A. Reviewing daily activated partial thromboplastin time (APTT) and prothrombin time.
• B. Reporting an APTT above 45 seconds to the physician
• C. Assessing the patient for signs and symptoms of frank and occult bleeding
• D. All of the above

Correct answer: D

Rationale: The correct answer is D. When a physician orders a maintenance dose of subcutaneous heparin, nursing responsibilities include reviewing daily activated partial thromboplastin time (APTT) and prothrombin time to monitor the patient's coagulation status, reporting an APTT above 45 seconds to the physician as it may indicate a risk of bleeding, and assessing the patient for signs and symptoms of frank and occult bleeding, which are potential adverse effects of anticoagulant therapy. Therefore, all the options listed are essential nursing responsibilities when a patient is on subcutaneous heparin therapy.

4. A client has unilateral paralysis and dysphagia following a right hemispheric stroke. Which of the following interventions should the nurse include in the plan?

• A. Place the client's left arm on a pillow while he is sitting.
• B. Provide total care in assisting with the client's ADLs.
• C. Encourage mobility and avoid bed rest.
• D. Facilitate feeding by placing food on the left side of the client's mouth when ready to eat.

Correct answer: A

Rationale: Placing the client's left arm on a pillow while sitting helps prevent shoulder displacement and assists in maintaining proper positioning and alignment. This intervention is crucial to prevent complications associated with immobility. Providing total care in ADLs may hinder the client's independence and recovery. Encouraging mobility is essential in preventing complications of immobility. Facilitating feeding by placing food on the unaffected side of the mouth helps reduce the risk of aspiration in clients with dysphagia.

5. Which of the following is a sign or symptom of a hemolytic reaction to a blood transfusion?

• A. Hemoglobinuria
• B. Chest pain
• C. Urticaria
• D. Distended neck veins

Correct answer: A

Rationale: Hemoglobinuria is a characteristic sign of a hemolytic reaction to a blood transfusion. Hemolytic reactions can lead to the destruction of red blood cells, causing the release of hemoglobin into the urine, which presents as hemoglobinuria. Chest pain, urticaria, and distended neck veins are not specific signs of a hemolytic reaction and may be associated with other conditions or reactions.

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