Nursing Elites

1. A client has pharyngeal diphtheria. Which of the following types of transmission precautions should the nurse initiate?

• A. Droplet
• B. Contact
• C. Airborne
• D. Protective

Correct answer: A

Rationale: Pharyngeal diphtheria is transmitted via droplets, primarily through respiratory secretions. Therefore, droplet precautions are necessary to prevent the spread of the infection. Droplet precautions involve wearing a surgical mask, goggles, and a gown when within three feet of the client. Contact precautions are used for diseases transmitted by direct or indirect contact; airborne precautions are for diseases transmitted through airborne particles; protective precautions are not a standard precaution type.

2. A nurse manager is overseeing the care on a unit. Which of the following should the nurse manager identify as a violation of HIPAA guidelines?

• A. A nurse who is caring for a client reviews the client's medical chart with the nursing student who is working with the nurse.
• B. A nurse asks a nurse from another unit to assist with her documentation.
• C. A nurse who is caring for a client returns a call to the client's durable power of attorney for health care designee to discuss the client's care.
• D. A nurse discusses a client's status with the physical therapist who is caring for the client at the bedside.

Correct answer: B

Rationale: The correct answer is B. HIPAA guidelines specify that only healthcare professionals directly involved in a patient's care should access their medical information. Asking a nurse from another unit to assist with documentation involves sharing patient information with someone not directly caring for the patient, which violates HIPAA guidelines. Choices A, C, and D involve individuals directly involved in the client's care, making them appropriate actions in line with HIPAA regulations. Choice A involves educating a nursing student under the supervision of the nurse, which is permissible. Choice C involves communicating with the client's designated healthcare decision-maker, which is also allowed under HIPAA. Choice D involves discussing the client's status with another healthcare professional directly involved in the client's care, which is within HIPAA guidelines.

3. When evaluating care of an immobilized patient, which action will the nurse take?

• A. Focus on whether the interdisciplinary team is satisfied with the care.
• B. Compare the patient's actual outcomes with the outcomes in the care plan.
• C. Involve primarily the patient's family and health care team to determine goal achievement.
• D. Use objective data solely in determining whether interventions have been successful.

Correct answer: B

Rationale: When evaluating the care of an immobilized patient, the nurse should focus on assessing outcomes and response to nursing care. By comparing the patient's actual outcomes with the outcomes identified during planning, the nurse can determine the effectiveness of the interventions implemented. This process allows for a comprehensive evaluation of the care provided. Choice A is incorrect because the satisfaction of the interdisciplinary team does not directly reflect the patient's outcomes and response to care. Choice C is incorrect as it mainly focuses on the involvement of the patient's family and healthcare team, which may not provide a holistic evaluation of the patient's care. Choice D is incorrect as relying solely on objective data may lead to overlooking important subjective aspects of the patient's response and outcomes, which are also crucial in evaluating care effectively.

4. A client with a diagnosis of hypertension is being assessed. Which symptom would be most concerning?

• A. Headache
• B. Blurred vision
• C. Dizziness
• D. Chest pain

Correct answer: D

Rationale: Chest pain in a client with hypertension is the most concerning symptom as it may indicate a myocardial infarction or other serious cardiac event related to hypertension. Immediate intervention is required to address potential life-threatening conditions. Headache, blurred vision, and dizziness are common symptoms associated with hypertension but are not typically indicative of an acute cardiac event requiring urgent attention.

5. A nurse is planning care for a client who reports abdominal pain. An assessment by the nurse reveals the client has a temperature of 39.2°C (102°F), heart rate of 105/min, a soft tender abdomen, and menses overdue by 2 days. Which of the following findings should be the nurse’s priority?

• A. Temperature
• B. Menses overdue
• C. Soft tender abdomen
• D. Heart rate

Correct answer: A

Rationale: The correct answer is A: Temperature. A high temperature of 39.2°C (102°F) indicates a fever, which can be a sign of infection or another serious condition. Investigating the cause of the fever is a priority to address any underlying health issue promptly. Menses overdue (choice B) could be relevant but is not as urgent as addressing a fever. A soft tender abdomen (choice C) is important but may be a consequence of the underlying condition causing the fever. Heart rate (choice D) is also significant, but the priority here is to identify the cause of the fever.

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