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 healthcare professional is reviewing the medical records of a client who has a pressure ulcer. Which of the following findings should the professional expect?

• A. Albumin level of 3
• B. Hemoglobin of 12
• C. Normal skin moisture
• D. No signs of infection

Correct answer: A

Rationale: The correct answer is A: Albumin level of 3. A low albumin level indicates poor nutrition, which can contribute to the development of pressure ulcers. Choice B, Hemoglobin of 12, is within the normal range and is not directly associated with pressure ulcers. Choice C, Normal skin moisture, does not provide specific information related to pressure ulcers. Choice D, No signs of infection, while important, is not a direct finding associated with pressure ulcers.

3. A nurse is developing a plan of care for an older adult who is at risk for falls. Which of the following actions should the nurse include?

• A. Lock beds and wheelchairs when not in use
• B. Administer a sedative at bedtime
• C. Provide information about home safety checks
• D. Teach balance and strengthening exercises

Correct answer: A

Rationale: The correct action for the nurse to include in the plan of care for an older adult at risk for falls is to lock beds and wheelchairs when not in use. This measure is crucial for preventing falls and ensuring patient safety in healthcare settings. Administering sedatives at bedtime (Choice B) is not recommended as it does not address the underlying risk factors for falls and may increase the risk of injury. Providing information about home safety checks (Choice C) is important for fall prevention in the home environment but is not directly related to healthcare settings. Teaching balance and strengthening exercises (Choice D) is beneficial for fall prevention but may not be suitable for all older adults at risk for falls, especially in acute care settings.

4. A nurse is monitoring an older adult female client who had a myocardial infarction (MI) for the development of an acute kidney injury (AKI). Which of the following findings should the nurse identify as indicating an increased risk of AKI?

• A. Magnesium 2.0 mEq/L
• B. Blood urea nitrogen (BUN) 20 mg/dL
• C. Serum Osmolality 290 mOsm/kg H2O
• D. Serum creatinine 1.8 mg/dL

Correct answer: D

Rationale: An elevated serum creatinine level (1.8 mg/dL) is a significant indicator of potential kidney impairment. In acute kidney injury (AKI), serum creatinine levels rise due to decreased kidney function, reflecting the kidneys' inability to effectively filter waste from the blood. Magnesium level, BUN, and serum osmolality are not direct indicators of kidney function or risk of AKI. Magnesium levels are more related to electrolyte balance, BUN can be affected by factors other than kidney function, and serum osmolality reflects the concentration of solutes in the blood, not specifically kidney function.

5. In a disaster where a building has collapsed, which victim should a nurse attend to first?

• A. A victim who has died of multiple serious injuries
• B. A victim with a partial amputation of a leg who is bleeding profusely
• C. An alert victim who has numerous bruises on the arms and legs
• D. A hysterical victim who has sustained a head injury

Correct answer: B

Rationale: In a disaster situation like a building collapse, the nurse should attend to the victim with a partial amputation of a leg who is bleeding profusely first. This victim is at immediate risk of severe blood loss, which can be life-threatening. It is crucial to address life-threatening injuries like severe bleeding before attending to other less urgent cases. The victim with the amputation requires immediate intervention to control bleeding and stabilize their condition. Victims who are already deceased or have less urgent injuries can be attended to after addressing the critical cases.

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