Nursing Elites

1. A nurse is observing a nursing student practicing standard precautions. Which observation by the instructor indicates that further teaching is necessary?

• A. The nursing student wears gloves when changing bed linens.
• B. The nursing student wears gloves to remove a wound dressing.
• C. The nursing student washes hands after removing gloves.
• D. The nursing student touches the patient's skin with sterile gloves.

Correct answer: D

Rationale: The correct answer is D because touching a patient's skin with sterile gloves compromises the sterility of the gloves, increasing the risk of contamination. Choices A, B, and C demonstrate correct practices in standard precautions. Wearing gloves when changing bed linens and to remove a wound dressing, as well as washing hands after removing gloves, are all appropriate and necessary steps to prevent the spread of infection.

2. A nurse is caring for a client who is requesting to leave the facility against medical advice (AMA). The client states, 'I am ready to go immediately.' Which of the following actions should the nurse take first?

• A. Teach the client about the potential health risks of leaving early
• B. Ask the client to sign a document stating they are leaving AMA
• C. Document the client's statement in direct quotes in the medical record
• D. Complete an incident report detailing the client scenario

Correct answer: A

Rationale: The correct action for the nurse to take first is to educate the client about the potential health risks of leaving against medical advice (AMA). By providing this information, the nurse can help the client make an informed decision regarding their healthcare. Choice B, asking the client to sign a document, can be done after the client has been informed about the risks. Choice C, documenting the client's statement, is important but should not take precedence over educating the client. Choice D, completing an incident report, is not the priority when a client is requesting to leave AMA.

3. A nurse manager on an acute care unit is preparing a staff presentation about promoting cost-effective care. Which of the following strategies should the nurse plan to include in the presentation?

• A. Change IV solution bags every 36 hr.
• B. Avoid the delegation of hygiene care to assistive personnel (AP)
• C. Wear sterile gloves when removing urinary retention catheters.
• D. Educate staff about the correct use of personal protective equipment (PPE) for isolation precautions

Correct answer: D

Rationale: Teaching staff proper use of PPE helps reduce the spread of infections and promotes cost-effective care.

4. The nurse is observing the way a patient walks. What aspect is the nurse assessing?

• A. Body alignment
• B. Gait
• C. Activity tolerance
• D. Range of motion

Correct answer: B

Rationale: The correct answer is B: Gait. Gait refers to the manner in which a person walks, including aspects such as stride length, step width, and walking speed. When a nurse observes a patient's gait, they are assessing their mobility and looking for any abnormalities or issues in their walking pattern. Choice A, body alignment, focuses more on the posture and position of the body rather than the actual walking pattern. Choice C, activity tolerance, relates to the ability to withstand physical activity without experiencing excessive fatigue. Choice D, range of motion, pertains to the extent of movement at a joint and is not directly related to observing the way a patient walks.

5. A nurse is preparing to administer medications to four clients. The nurse should administer medications to which client first?

• A. A client who has pneumonia and a WBC count of 11,500/mm3 prescribed piperacillin
• B. A client who has renal failure and a serum potassium of 5.8 mEq/L prescribed sodium polystyrene sulfonate
• C. A client who is post-coronary artery bypass graft (CABG) prescribed atorvastatin
• D. A client who has anemia and a hemoglobin level of 11g/dL prescribed epoetin alfa

Correct answer: B

Rationale: The correct answer is B. The client with renal failure and high potassium levels requires immediate attention because hyperkalemia can lead to life-threatening cardiac complications. Administering sodium polystyrene sulfonate helps lower the potassium levels. Choice A, the client with pneumonia and a high WBC count, although important, does not present an immediate life-threatening condition. Choice C, the post-CABG client prescribed atorvastatin, and Choice D, the client with anemia and a hemoglobin level of 11g/dL prescribed epoetin alfa, do not require immediate intervention compared to managing hyperkalemia in a client with renal failure.

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