Nursing Elites

1. A nurse is caring for a young adult at a college health clinic. Which of the following actions should the nurse take first?

• A. Give the client information about immunization against meningitis.
• B. Tell the client to have a TB skin test every 2 years.
• C. Determine the client’s health risks.
• D. Teach the client about exercise recommendations.

Correct answer: C

Rationale: Assessing the client’s health risks is the priority as it provides essential information to guide subsequent care. By understanding the client’s health risks, the nurse can tailor health education and interventions, such as immunizations and lifestyle modifications, to address specific needs. Providing information about immunization against meningitis (Choice A) is important but should come after assessing health risks. Instructing the client to have a TB skin test every 2 years (Choice B) is relevant but not the initial step in care. Teaching about exercise recommendations (Choice D) is also essential but should follow the assessment of health risks.

2. Why should a client with an ileal conduit be instructed to empty the collection device frequently?

• A. Force urine to back up into the kidneys.
• B. Suppress production of urine.
• C. Cause the device to pull away from the skin.
• D. Tear the ileal conduit

Correct answer: C

Rationale: A full urine collection bag can cause the device to pull away from the skin, leading to potential leakage and skin irritation. Choice A is incorrect because a full urine collection bag does not force urine to back up into the kidneys. Choice B is incorrect as a full collection bag does not suppress the production of urine. Choice D is incorrect as a full collection bag is unlikely to tear the ileal conduit.

3. The nurse is preparing to provide a complete bed bath to an unconscious patient. The nurse decides to use a bag bath. In which order will the nurse clean the body, starting with the first area?

• A. Neck, shoulders, and chest
• B. Abdomen and groin/perineum
• C. Legs, feet, and web spaces
• D. Back of neck, back, and then buttocks

Correct answer: B

Rationale: In providing a complete bed bath using a bag bath for an unconscious patient, the nurse should follow a specific order. The correct sequence is as follows: Neck, shoulders, and chest; Both arms, both hands, web spaces, and axilla; Abdomen and then groin/perineum; Right leg, right foot, and web spaces; Left leg, left foot, and web spaces; Back of neck, back, and then buttocks. Choice A is incorrect as it does not follow the correct sequence for a bed bath. Choice C is incorrect as it focuses on the lower extremities before addressing the upper body. Choice D is incorrect as it starts with the back of the patient instead of the upper body areas first.

4. A client is recovering from gallbladder surgery performed under general anesthesia. How many times per hour should the nurse encourage the client to use the incentive spirometer?

• A. 4-5 times per hour
• B. 2-3 times per hour
• C. 6-7 times per hour
• D. 8-10 times per hour

Correct answer: A

Rationale: Encouraging the client to use the incentive spirometer 4-5 times per hour is the correct approach post-gallbladder surgery under general anesthesia. This frequency helps prevent respiratory complications, such as atelectasis, by promoting lung expansion. Choices B, C, and D suggest either too few or too many sessions per hour, which may not be optimal for the client's respiratory recovery needs. It is important to strike a balance between ensuring adequate lung expansion and not overexerting the client, which is why 4-5 times per hour is the recommended frequency.

5. 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.

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