Nursing Elites

1. During an initial history and physical assessment of a 3-month-old brought into the clinic for spitting up and excessive gas, what would the nurse expect to find?

• A. Increased temperature and lethargy
• B. Restlessness and increased mucus production
• C. Increased sleeping and listlessness
• D. Diarrhea and poor skin turgor

Correct answer: B

Rationale: Restlessness and increased mucus production are common signs of gastrointestinal issues or reflux in infants, which could explain the symptoms of spitting up and excessive gas. Increased temperature and lethargy (Choice A) are more indicative of an infection rather than gastrointestinal issues. Increased sleeping and listlessness (Choice C) are not typical signs associated with the symptoms described. Diarrhea and poor skin turgor (Choice D) are not directly related to the symptoms of spitting up and gas in this scenario.

2. A nurse is caring for a client who is postoperative and has signs of hemorrhagic shock. When the nurse notifies the surgeon, he directs her to continue measuring the client's vital signs every 15 minutes and call him back in 1 hour. From a legal perspective, which of the following actions should the nurse take next?

• A. Document the provider's directive in the medical record
• B. Notify the nursing manager
• C. Consult the facility's risk manager
• D. Complete an incident report

Correct answer: B

Rationale: In this scenario, the nurse is facing a critical situation with a client showing signs of hemorrhagic shock. The surgeon's directive of waiting for an hour without providing immediate intervention poses a risk to the client's well-being. The nurse should prioritize the client's safety and advocate for timely and appropriate care. Notifying the nursing manager is the correct action as it activates the chain of command to ensure that the client receives the necessary care promptly. Documenting the provider's directive, consulting the risk manager, or completing an incident report are not the immediate actions needed to address the client's deteriorating condition and ensure patient safety.

3. In an emergency situation, the charge nurse on the night shift at an urgent care center has to deal with admitting clients of higher acuity than usual due to a large fire in the area. Which style of leadership and decision-making would be best in this circumstance?

• A. Assume a decision-making role
• B. Seek input from staff
• C. Use a non-directive approach
• D. Shared decision-making with others

Correct answer: A

Rationale: In an emergency situation such as dealing with patients of higher acuity due to a large fire, it is crucial for the charge nurse to assume a decision-making role. This style of leadership allows for quick and efficient decision-making to manage the increased acuity of patients effectively. Seeking input from staff (Choice B) may delay critical decisions needed in emergencies. Using a non-directive approach (Choice C) or shared decision-making with others (Choice D) may not be suitable in urgent situations where immediate actions are required to address the high acuity of patients.

4. A nurse on a rehabilitation unit is preparing to transfer a client who is unable to walk from bed to a wheelchair. Which of the following techniques should the nurse use?

• A. Place the wheelchair at a 45-degree angle to the bed
• B. Position the wheelchair parallel to the bed
• C. Place the wheelchair in front of the bed
• D. Have the client stand and pivot into the wheelchair

Correct answer: A

Rationale: Placing the wheelchair at a 45-degree angle to the bed is the correct technique for transferring a client who is unable to walk from bed to a wheelchair. This positioning facilitates a safer and easier transfer by providing more space for maneuvering and reducing the distance the client needs to be moved. Positioning the wheelchair parallel to the bed (Choice B) may make the transfer more challenging due to limited space and a longer distance to move the client. Placing the wheelchair in front of the bed (Choice C) may not provide an optimal angle for the transfer. Having the client stand and pivot into the wheelchair (Choice D) is not appropriate for a client who is unable to walk and could increase the risk of falls or injuries during the transfer.

5. The nurse is preparing to assist a newly admitted client with personal hygiene measures. The nurse wants to assess the client's gag reflex. Which action should the nurse include?

• A. Offer small sips of water through a straw
• B. Place tongue blade on back half of tongue
• C. Use a penlight to observe back of the oral cavity
• D. Auscultate breath sounds after the client swallows

Correct answer: B

Rationale: The correct action for the nurse to include when assessing the client's gag reflex is to place a tongue blade on the back half of the tongue. This method effectively tests the gag reflex without causing discomfort. Choice A is incorrect because offering small sips of water through a straw does not assess the gag reflex. Choice C is incorrect as using a penlight to observe the back of the oral cavity does not directly assess the gag reflex. Choice D is incorrect since auscultating breath sounds after the client swallows does not evaluate the gag reflex.

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