Nursing Elites

1. A nurse observes a colleague ignoring proper hand hygiene protocols. What should the nurse do first?

• A. Speak to the colleague directly.
• B. Ignore the situation, as it doesn't involve direct patient care.
• C. Report the colleague to the nursing manager.
• D. File an incident report immediately.

Correct answer: D

Rationale: The correct first action for the nurse to take in this situation is to file an incident report immediately. By doing so, the nurse ensures that the unsafe practice is documented for further investigation and corrective action. Speaking to the colleague directly may not address the root cause of the issue and could lead to potential conflicts. Ignoring the situation is not an appropriate response as it compromises patient safety. Reporting the colleague to the nursing manager should be done after filing an incident report to ensure that appropriate actions are taken to prevent future occurrences of non-compliance with hand hygiene protocols.

2. During a home visit with an older adult client, a nurse should address which of the following observations to promote a safe environment?

• A. Loud volume of the television set
• B. Wall-to-wall carpet in the living room
• C. Low chairs without armrests
• D. Use of indirect lighting

Correct answer: C

Rationale: The correct answer is C: Low chairs without armrests. This observation should be addressed by the nurse to promote a safe environment for the older adult client. Low chairs without armrests increase the risk of falls as they can be challenging for older adults to sit down on or get up from. Addressing this issue can help prevent falls and promote safety. Choices A, B, and D are not as crucial for promoting a safe environment compared to the risk posed by low chairs without armrests.

3. A client is prescribed 1g of potassium phosphate IV to be infused continuously over 6 hr. Available is 1 g in 250 ml of dextrose 5%. What rate should the nurse set the IV pump to run at?

• A. 40 ml/hr
• B. 42 ml/hr
• C. 44 ml/hr
• D. 46 ml/hr

Correct answer: B

Rationale: To calculate the IV rate, divide the total volume by the total time in hours. In this case, 1 g in 250 ml is to be infused over 6 hours. Therefore, 250 ml / 6 hr = 42 ml/hr. This means the IV pump should be set to run at 42 ml/hr. Choices A, C, and D are incorrect as they do not accurately calculate the infusion rate based on the provided information.

4. What is the primary intervention for a client diagnosed with delirium?

• A. Provide a quiet and calm environment to minimize confusion
• B. Administer medication to reverse the symptoms of delirium
• C. Provide opportunities for social interaction to reduce isolation
• D. Encourage the client to remain physically active

Correct answer: A

Rationale: The correct answer is A: Provide a quiet and calm environment to minimize confusion. For clients diagnosed with delirium, creating a tranquil setting can help reduce agitation and disorientation. This intervention aims to decrease stimuli that may exacerbate symptoms. Administering medication (choice B) is not the primary intervention for delirium; it is usually reserved for specific underlying causes. While social interaction (choice C) and physical activity (choice D) are beneficial for overall well-being, they are not the primary interventions for managing delirium.

5. A client undergoing surgery refuses to remove religious jewelry. What is the best course of action?

• A. Proceed with surgery while securing the jewelry to the patient.
• B. Remove the jewelry and document the removal.
• C. Document the refusal and delay the surgery.
• D. Remove the jewelry with the family's permission.

Correct answer: B

Rationale: The correct course of action is to remove the jewelry and document the removal. While religious beliefs should be respected, ensuring patient safety during surgery is crucial. Securing the jewelry may not be sufficient to prevent any interference during the surgical procedure. Documenting the removal is important for legal and documentation purposes. Delaying the surgery or removing the jewelry with the family's permission may not be the best options as patient safety should be the top priority in this situation.

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