Nursing Elites

1. Which of the following is true of advanced directives?

• A. They should be appropriately documented in the client's chart.
• B. They are only applicable if the client has a terminal illness.
• C. They are required if the client is unconscious.
• D. They are non-legal requests.

Correct answer: A

Rationale: The correct answer is that advanced directives should be appropriately documented in the client's chart. Advanced directives are legal requests regarding a client's healthcare that come into effect under specific circumstances, regardless of the severity of their illness or level of consciousness. Choice B is incorrect because advanced directives can cover various healthcare decisions, not just terminal illnesses. Choice C is incorrect as advanced directives can be established and documented while the client is conscious, not only if they are unconscious. Choice D is incorrect because advanced directives are indeed legal requests, not non-legal requests.

2. A client has been placed in isolation because he is diagnosed with a contagious illness. The nurse should be aware that:

• A. Linens from the client's bed should be double-bagged.
• B. Meals should be served on washable dishes.
• C. Extensive isolation rarely causes psychological problems.
• D. Paper trays and plastic utensils do not prevent disease transmission.

Correct answer: A

Rationale: Isolation techniques are used to prevent or limit the spread of infection. Special handling of articles and linens soiled by any body fluid is essential. Linens should be placed in impervious bags before being removed from the client's bedside to prevent exposure of personnel and contamination of the environment. Double-bagging is required if the outside of the bag becomes contaminated. This practice ensures that potentially infectious materials are properly contained and disposed of. Choices B, C, and D are incorrect because the focus in this scenario is on proper handling and disposal of soiled linens to prevent the spread of infection, not on serving meals, psychological effects of isolation, or the use of paper trays and plastic utensils.

3. After securing the client's safety from a faulty electric bed, what should the nurse do next?

• A. Discuss the matter with the client's significant others.
• B. Document the incident in the client's record in detail.
• C. Notify the physician.
• D. Prepare an incident report.

Correct answer: D

Rationale: After ensuring the client's safety from the faulty electric bed, the nurse should prioritize preparing an incident report. This report documents the details of what happened and is crucial for quality improvement and risk management. Choice A, discussing the matter with the client's significant others, may be important in some cases but is not the immediate priority after a safety incident. Choice B, documenting the incident in the client's record, is necessary but should be preceded by preparing an incident report. Choice C, notifying the physician, is important but not as urgent as preparing the incident report to ensure timely reporting and investigation of the safety issue.

4. All of the following tasks could be delegated to a nursing assistant or unlicensed assistive personnel (UAP) except:

• A. monitoring intravenous infusion
• B. assisting a client to the bathroom
• C. offering fluid intake every 1-2 hours
• D. monitoring/recording the amount of fluid taken

Correct answer: A

Rationale: Monitoring an intravenous infusion involves assessing for complications, adjusting the flow rate, and monitoring the client's response, which requires the knowledge and skills of a licensed nurse (RN or LPN). Tasks that can be delegated to nursing assistants or unlicensed assistive personnel include assisting a client to the bathroom, offering fluids, and recording fluid intake. These activities are within the scope of practice for UAPs as they do not involve the specialized knowledge and training needed for intravenous infusion monitoring.

5. A licensed practical nurse arrives at work at the long-term care center and is immediately faced with several activities that require attention. Which activity will the nurse attend to first?

• A. Task assignments for the day
• B. Stocking the medication closet
• C. A phone message from employee health services
• D. A phone message from a client's wife

Correct answer: A

Rationale: The nurse's priority should be attending to task assignments for the day. This ensures that client care can begin promptly and efficiently. Stocking the medication closet is important but can be done after ensuring task assignments are clear. Phone messages from employee health services and a client's wife, although important, can be addressed after organizing the staff for client care.

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