Nursing Elites

1. While in the cafeteria, a nurse overhears two APs discussing a hospitalized patient. What action should the nurse take?

• A. Report the incident to the supervisor.
• B. Join the conversation to intervene.
• C. Quietly tell the APs that this is not appropriate.
• D. Ignore the conversation.

Correct answer: C

Rationale: The correct action for the nurse to take in this situation is to choose option C: 'Quietly tell the APs that this is not appropriate.' The nurse should immediately and discreetly address the situation, reminding the APs that discussing patient information in public areas violates confidentiality. Reporting the incident to the supervisor (option A) may be necessary if the behavior continues. Joining the conversation to intervene (option B) may escalate the situation and compromise patient confidentiality. Ignoring the conversation (option D) does not address the violation or prevent it from recurring.

2. A nurse is assessing a 2-hour-old newborn for cold stress. Which of the following findings should the nurse expect?

• A. Respiratory rate of 60/min
• B. Jitteriness of the hands
• C. Diaphoresis
• D. Bounding peripheral pulses

Correct answer: B

Rationale: The correct answer is B: Jitteriness of the hands. Jitteriness is a key sign of cold stress in a newborn, indicating the need for immediate warming measures. A respiratory rate of 60/min may not be directly indicative of cold stress. Diaphoresis (excessive sweating) and bounding peripheral pulses are not typical findings associated with cold stress in newborns.

3. A client who is 38 weeks pregnant with herpes simplex virus is admitted to labor and delivery. What question should the nurse ask?

• A. Do you have any active lesions?
• B. Have your membranes ruptured?
• C. How far apart are your contractions?
• D. Are you positive for beta strep?

Correct answer: A

Rationale: The correct question the nurse should ask the client who is 38 weeks pregnant with herpes simplex virus is 'Do you have any active lesions?' This is crucial because active herpes lesions may necessitate a cesarean delivery to prevent neonatal infection. Choice B, 'Have your membranes ruptured?' is related to assessing for the rupture of membranes, not specific to the client's herpes infection. Choice C, 'How far apart are your contractions?' is related to monitoring labor progress. Choice D, 'Are you positive for beta strep?' is related to group B streptococcus screening, which is important but not the priority in this scenario.

4. A nurse is caring for a group of clients in a long-term care facility. Which of the following situations should the nurse recognize as a safety hazard?

• A. A client’s wrist restraints tied to the bed rails
• B. A client’s bedside table placed across the foot of the bed
• C. A meal tray left at the bedside from breakfast
• D. A call light extension cord pinned to the bedspread

Correct answer: A

Rationale: The correct answer is A. Tying wrist restraints to the bed rails is a safety hazard because if the bed rails are lowered, the restraints can tighten and cause injury or asphyxiation. Choice B, placing a bedside table across the foot of the bed, may not be ideal for convenience but does not pose a direct safety hazard. Choice C, leaving a meal tray at the bedside from breakfast, is more of an infection control issue than an immediate safety hazard. Choice D, having a call light extension cord pinned to the bedspread, is also not a direct safety hazard unless it poses a risk of entanglement or tripping, which is not indicated in the scenario.

5. A nurse is supervising an LPN who is providing care to a patient who is postoperative. Which of the following statements by the patient requires the nurse to follow up with the LPN?

• A. “I am experiencing some pain, but it’s tolerable.”
• B. “The nurse checked my vital signs earlier.”
• C. “I have not received any of my medications today.”
• D. “I am scheduled for therapy later today.”

Correct answer: C

Rationale: If the patient states they have not received any medications, it requires immediate follow-up to prevent missed doses and complications. The other options do not pose an immediate risk to the patient. Option A indicates pain but is tolerable, which is a common postoperative experience. Option B states that vital signs were checked, indicating ongoing monitoring. Option D mentions therapy, which is a scheduled activity and not an urgent concern regarding medication administration.

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