Nursing Elites

1. A nurse is assigned to care for four clients. Which client should the nurse assess first?

• A. A client scheduled for a colonoscopy
• B. A client with a tracheostomy who is receiving humidified oxygen via a tracheostomy mask
• C. A client preparing for discharge after surgery
• D. A client requiring a tube feeding through a gastrostomy tube

Correct answer: B

Rationale: The correct answer is a client with a tracheostomy who is receiving humidified oxygen via a tracheostomy mask. Airway management is always the priority in nursing care. Assessing this client first ensures that their airway is clear and oxygenation is adequate. Clients with compromised airways need immediate attention to prevent respiratory distress or failure. The other clients do not have immediate airway concerns and represent lower priorities in this scenario. Therefore, the nurse should prioritize assessing the client with the tracheostomy and oxygen therapy to maintain airway patency and adequate oxygenation.

2. A nurse and a nursing assistant enter a client's room to provide care and find the client lying on the floor. Which action should the nurse take first?

• A. Ask the nursing assistant to complete an incident report
• B. Check the client's level of consciousness and vital signs
• C. Contact the unit secretary on the intercom and ask that the client's health care provider be called
• D. Ask the nursing assistant to assist in getting the client back to bed

Correct answer: B

Rationale: When a client sustains a fall, the nurse must first assess the client. The nurse should check the client's level of consciousness and vital signs to determine the severity of the situation and provide appropriate care promptly. This immediate assessment is crucial in ensuring the client's immediate needs are addressed. Asking the nursing assistant to complete an incident report (choice A) is not the priority as the client's condition needs immediate attention. Contacting the unit secretary to call the client's health care provider (choice C) can be done after the initial assessment has been completed. Asking the nursing assistant to assist in getting the client back to bed (choice D) should only be considered after ensuring the client is stable and safe to move.

3. When are standard walkers typically used?

• A. When clients have poor balance, cannot stand up, have weak arms, and good hand strength.
• B. When clients have poor balance, have a broken leg, or have experienced amputation.
• C. When clients have poor balance, have cardiac problems, or cannot use crutches or a cane.
• D. When clients have poor balance, have an autoimmune disease, or have weak arms.

Correct answer: C

Rationale: Standard walkers are typically used for clients who have poor balance, cardiac problems, or those who cannot use crutches or a cane. The rationale is correct in stating that a walker is suitable for individuals needing to bear partial weight and having strength in their wrists and arms to propel the walker forward. Choices A, B, and D are incorrect because they do not accurately reflect the main reasons why standard walkers are used in clinical practice. Using a walker is not solely about having weak arms, good hand strength, a broken leg, experienced amputation, or an autoimmune disease. The primary focus is on addressing balance issues, cardiac problems, or the inability to use crutches or a cane effectively.

4. Under what circumstances is the legal right to confidentiality of client information waived?

• A. When a court system subpoenas information.
• B. When a family member requests health care information of a client.
• C. When a living will takes effect.
• D. When the client is declared incompetent by the legal system.

Correct answer: A

Rationale: The legal right to confidentiality of client information is waived when a court system subpoenas information. This occurs when information is required for legal proceedings to occur, such as through summonses, court orders, or litigation information necessary for the court. Subpoenas are legal orders that compel the disclosure of information. The other choices do not inherently waive the legal right to confidentiality. A family member's request for health care information would typically require the client's consent or fall under specific legal exceptions. A living will dictates end-of-life care preferences but does not necessarily waive confidentiality. Lastly, the declaration of incompetence may impact decision-making capacity but does not automatically waive confidentiality.

5. The nurse is teaching a client about erythema infectiosum. Which of the following factors is not correct?

• A. There is no rash.
• B. The disorder is uncommon in adults.
• C. There is no fever.
• D. There is sometimes a 'slapped face' appearance.

Correct answer: B

Rationale: The correct answer is that the disorder is uncommon in adults. Erythema infectiosum, also known as Fifth's disease, commonly affects children and is characterized by a 'slapped face' appearance. It is associated with a rash and sometimes a low-grade fever. Therefore, the statement 'The disorder is uncommon in adults' is not correct, making it the correct answer. The other statements about the presence of a rash, 'slapped face' appearance, and the possibility of a fever are accurate in the context of erythema infectiosum.

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