Nursing Elites

1. While walking in the hallway of an acute care unit of the hospital, the nurse overhears the change of shift report. What should the nurse do?

• A. Make the charge nurse on the unit aware of the situation so that they can take the necessary steps to maintain the confidentiality of the information being reported.
• B. Disregard the information because it changes quickly on the acute care unit and is outdated within 2-3 hours anyway.
• C. Return to their own unit and not disclose that confidential information has been overheard.
• D. Ignore the situation.

Correct answer: A

Rationale: To protect the confidentiality of the information being reported, the nurse should make the charge nurse on the unit aware of the situation. This allows the charge nurse to take necessary steps to maintain confidentiality and ensure that the information is communicated in an appropriate and private manner. Disclosing the situation to the charge nurse is essential to address any breaches in confidentiality and uphold professional standards of privacy and ethics. Disregarding the information, returning to their own unit without disclosure, or ignoring the situation altogether would not address the breach of confidentiality and could lead to further issues regarding patient privacy and trust.

2. Which action by the novice nurse indicates a need for further teaching?

• A. The nurse fails to wear gloves when removing a dressing.
• B. The nurse applies an oxygen saturation monitor to the earlobe.
• C. The nurse elevates the head of the bed to check blood pressure.
• D. The nurse places the extremity in a dependent position to acquire a peripheral blood sample.

Correct answer: A

Rationale: The correct answer is A. The novice nurse failing to wear gloves when removing a dressing indicates a need for further teaching to emphasize infection control practices. This action can lead to the spread of infections. Choices B, C, and D are incorrect because they demonstrate proper nursing skills and techniques. Applying an oxygen saturation monitor to the earlobe, elevating the head of the bed to check blood pressure, and placing the extremity in a dependent position to acquire a peripheral blood sample all reflect understanding of correct procedures in patient care.

3. How can the nurse best communicate to a client that he or she has been listening?

• A. restating the main feeling or thought the client has expressed
• B. making a judgment about the client's problem
• C. offering a leading question such as, 'And then what happened?'
• D. saying, 'I understand what you're saying.'

Correct answer: A

Rationale: The best way for the nurse to communicate to a client that he or she has been listening is by restating the main feeling or thought the client has expressed. Restating helps the client validate the nurse's understanding of the communication, demonstrating active listening skills. Making judgments about the client's problem, as suggested in Choice B, can hinder effective communication by introducing bias and potential misinterpretation. Offering a leading question like in Choice C is not ideal for confirming understanding; it rather seeks more information. Choice D, simply saying 'I understand what you're saying,' may not convey active listening as effectively as restating the client's main feelings or thoughts, as it lacks the validation component present in restating.

4. The nurse is caring for a client scheduled for a surgical repair of a sacular abdominal aortic aneurysm. Which assessment is most crucial during the preoperative period?

• A. Assessment of the client's level of anxiety
• B. Evaluation of the client's exercise tolerance
• C. Identification of peripheral pulses
• D. Assessment of bowel sounds and activity

Correct answer: C

Rationale: The most crucial assessment during the preoperative period for a client with a sacular abdominal aortic aneurysm scheduled for surgical repair is the identification of peripheral pulses. During surgery, the aorta will be clamped, potentially affecting blood circulation to the kidneys and lower extremities. Therefore, it is essential for the nurse to assess peripheral pulses and monitor the return of circulation to the lower extremities postoperatively. Assessing the client's level of anxiety (Choice A) is important but not as crucial as ensuring adequate circulation. Evaluating exercise tolerance (Choice B) is not recommended preoperatively for this situation. Assessing bowel sounds and activity (Choice D) is of lesser concern compared to the critical need to monitor peripheral circulation.

5. During a well-baby check of a 6-month-old infant, the nurse notes abrasions and petechiae of the palate. The nurse should:

• A. inquire about the possibility of sexual abuse.
• B. ask about the types of foods the child is eating.
• C. request to see the type of bottle used for feedings.
• D. question the parent about objects the child plays with.

Correct answer: A

Rationale: The correct answer is to inquire about the possibility of sexual abuse. Injuries to the soft palate such as bruising, abrasions, and petechiae can be signs of sexual abuse in infants. While oral sex may not leave significant physical evidence, these findings should raise suspicion. Option A is correct as it focuses on addressing potential abuse. Options B, C, and D are incorrect because the child's diet, the type of bottle used for feedings, and play objects are not likely related to the observed injuries. The presence of oral injuries suggests considering sexual abuse rather than other factors.

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