Nursing Elites

1. A nurse observes a colleague not using proper hand hygiene. What should the nurse do first?

• A. Ignore the behavior and continue with care
• B. Discuss the behavior with other colleagues
• C. Confront the colleague about the behavior
• D. Report the behavior to the supervisor

Correct answer: D

Rationale: The correct action for the nurse to take first is to report the behavior to the supervisor. Proper hand hygiene is essential in preventing the spread of infections in healthcare settings. By reporting the observed behavior to the supervisor, the nurse is prioritizing patient safety and promoting a culture of accountability. Ignoring the behavior (Choice A) can put patients at risk, discussing it with other colleagues (Choice B) may not address the issue effectively, and confronting the colleague directly (Choice C) might not be the most appropriate initial step and could lead to conflicts rather than a constructive resolution.

2. A nurse is preparing to administer a blood transfusion. What is the most important action to ensure patient safety?

• A. Check the patient's vital signs every 15 minutes during the transfusion.
• B. Verify the patient's identity with two identifiers before starting the transfusion.
• C. Ensure the blood product is administered within 4 hours of removal from the blood bank.
• D. Ensure the patient has signed the informed consent form.

Correct answer: B

Rationale: The most important action to ensure patient safety when administering a blood transfusion is to verify the patient's identity with two identifiers before starting the transfusion. This step is crucial to prevent transfusion errors, such as giving the blood to the wrong patient. Checking vital signs, ensuring timely administration, and confirming informed consent are also important aspects of blood transfusion safety but verifying the patient's identity is the highest priority to prevent errors.

3. A nurse is preparing to transfer a client who can bear weight on one leg from the bed to a chair. After securing a safe environment, which of the following actions should the nurse take next?

• A. Check for orthostatic hypotension
• B. Use a gait belt
• C. Position the chair on the strong side
• D. Ask for assistance

Correct answer: A

Rationale: The correct next action for the nurse to take is to check for orthostatic hypotension. This step is crucial as it ensures the client's safety during the transfer process. Orthostatic hypotension is a drop in blood pressure that can occur when a person moves from a lying down position to a sitting or standing position. By checking for orthostatic hypotension before transferring the client, the nurse can prevent potential complications such as dizziness, lightheadedness, or falls. Choices B, C, and D are incorrect in this scenario as they do not address the immediate safety concern of assessing for orthostatic hypotension.

4. A nurse is receiving change-of-shift report on a group of clients. Which of the following clients should the nurse assess first?

• A. A client who has urolithiasis and reports severe ankle pain extending toward the abdomen
• B. A client who has acute cholecystitis and reports abdominal pain radiating to the right shoulder
• C. A client who has had a total knee arthroplasty, is 1 day postoperative, and reports a pain level of 8 on a 0 to 10 pain scale
• D. A client who has a fractured femur and reports sudden sharp chest pain

Correct answer: D

Rationale: The correct answer is D because a client with a fractured femur and sudden chest pain may be experiencing a pulmonary embolism, which requires immediate assessment. Choice A is incorrect because although severe pain is present, it is more indicative of musculoskeletal issues related to urolithiasis rather than a life-threatening condition. Choice B, related to acute cholecystitis, is less urgent than choice D as the pain radiating to the right shoulder is a common symptom but does not indicate an immediate life-threatening situation. Choice C, regarding a client post-total knee arthroplasty with a pain level of 8, is important but not as urgent as a potential pulmonary embolism in choice D.

5. What should be done to manage a patient with contact precautions?

• A. Wear a mask, gown, and gloves for all patient interactions.
• B. Ensure that visitors wear protective equipment.
• C. Dedicate all patient care equipment to that patient.
• D. Disinfect shared equipment before use.

Correct answer: C

Rationale: When managing a patient with contact precautions, it is essential to dedicate all patient care equipment to that specific patient. This practice helps minimize the risk of spreading infections to other patients. Choice A, wearing protective gear for all patient interactions, is a general precaution but not specific to managing a patient with contact precautions. Choice B, ensuring visitors wear protective equipment, is important for infection control but not directly related to managing the patient with contact precautions. Choice D, disinfecting shared equipment before use, is a good practice for infection control in general but does not address the specific needs of a patient under contact precautions.

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