Nursing Elites

1. As a charge nurse, what is your primary responsibility for a 50-year-old blind and deaf patient admitted to your floor?

• A. Inform others about the patient's deficits.
• B. Communicate patient safety concerns to your supervisor.
• C. Provide continuous updates to the patient about the social environment.
• D. Provide a secure environment for the patient.

Correct answer: D

Rationale: The primary responsibility of the charge nurse for a blind and deaf patient is to provide a secure environment. Ensuring patient safety is crucial to prevent medical errors and adverse outcomes. By creating a safe environment, the nurse can protect the patient from harm and promote well-being. Option A is incorrect as the focus should be on ensuring patient safety rather than highlighting deficits. Option B is not the primary responsibility in this scenario, as the immediate concern is the patient's safety. Option C is irrelevant and does not address the patient's primary needs, which are safety and security.

2. When assessing the pulse of a 6-year-old patient, the nurse notices that the heart rate varies with the respiratory cycle, speeding up at the peak of inspiration and slowing to normal with expiration. What action would the nurse take next?

• A. Notify the physician.
• B. Record this finding as normal.
• C. Check the child's blood pressure and note any variation with respiration.
• D. Document that this child has bradycardia and continue with the assessment.

Correct answer: B

Rationale: The correct action for the nurse to take next is to record this finding as normal. Sinus dysrhythmia, characterized by heart rate variation with the respiratory cycle, is commonly found in children and young adults. The heart rate speeds up at the peak of inspiration and slows to normal with expiration. This phenomenon is a normal variant and does not require any intervention. There is no need to notify the physician as this finding is within the expected range for this age group. Checking the child's blood pressure for variations with respiration or documenting the child as having bradycardia would not be appropriate in this case, as sinus dysrhythmia is a normal physiological response.

3. A patient's Foley catheter has been discontinued. You will dispose of this patient equipment by doing which of the following?

• A. Wearing gloves and then placing this equipment in the regular trash can after it is placed in a paper bag.
• B. Simply placing this equipment in the regular trash can after it is placed in a paper bag.
• C. Wearing gloves and then placing this equipment into a special 'hazardous waste' container.
• D. Simply placing this equipment in the 'hazardous waste' container after it is placed in a paper bag.

Correct answer: C

Rationale: When disposing of used patient equipment, such as a Foley catheter, that has come in contact with bodily fluids, it is considered hazardous waste. The correct procedure involves wearing gloves and placing the Foley bag and tubing into a special 'hazardous waste' container. This container is marked as 'Hazardous' and is typically red to indicate the potential danger of its contents. Placing the equipment in a regular trash can, even if placed in a paper bag, is not appropriate as it does not meet the standards for disposing of hazardous waste. Therefore, options A and B are incorrect. Similarly, simply placing the equipment in a 'hazardous waste' container after it is placed in a paper bag is also incorrect as direct disposal into the designated container while wearing gloves is the proper protocol, making option D incorrect.

4. Efforts by healthcare facilities to reduce the incidence of hospital-acquired infections (HAIs) include an awareness of which of the following?

• A. The CDC requires all states to report HAI rates from each hospital.
• B. Ensure that the restraints are tied to the side rails.
• C. The gastrointestinal tract is a common site for HAIs.
• D. Joint Commission considers death or serious injury from HAIs a sentinel event.

Correct answer: D

Rationale: Efforts to reduce hospital-acquired infections (HAIs) involve being aware that the Joint Commission considers death or serious injury resulting from HAIs a sentinel event, which must be reported. While more than 20 states require reporting of HAI rates to the CDC, it is not a nationwide CDC requirement. The gastrointestinal tract is not a specific common site for HAIs; rather, bacteria are the primary cause. Ensuring restraints are properly secured is important for patient safety but not directly related to reducing HAIs.

5. While explaining an illness to a 10-year-old, what should the nurse keep in mind about the cognitive development at this age?

• A. They are able to make simple associations of ideas
• B. They are able to think logically in organizing facts
• C. Interpretation of events originates from their own perspective
• D. Conclusions are based on previous experiences

Correct answer: B

Rationale: At the age of 10, children are in the concrete operations stage according to Piaget. They are capable of mature thought when allowed to manipulate and organize objects. This means they can think logically, organize facts, and understand cause-and-effect relationships. Choices A, C, and D are incorrect. While simple associations of ideas may occur, the key cognitive ability at this stage is the capacity for logical thought and organization of information. Interpretation of events from their own perspective is more characteristic of younger children, and conclusions based on previous experiences are more aligned with older children or adults.

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