Nursing Elites

1. A nursing instructor asks a nursing student to describe accountability. Which statement(s) by the student indicate(s) an accurate description of accountability?

• A. Check the unit policy for the protocol for the care of clients who have been sexually assaulted.
• B. Ask a medical assistant.
• C. Call the nurse in charge of the day shift.
• D. Ask the police officers who brought the client to the center.

Correct answer: A

Rationale: Accountability in nursing involves taking responsibility for one's actions and decisions. In this scenario, checking the unit policy for the protocol related to the care of sexually assaulted clients demonstrates accountability. Policies and protocols provide guidance on appropriate actions and responsibilities in specific situations. Asking a medical assistant, calling the day shift nurse in charge, or consulting police officers are not appropriate actions to demonstrate accountability in this context. Seeking further clarification from the agency nursing supervisor on the night shift after reviewing the policy or protocol would be a more suitable course of action.

2. What is involved in client education by the nurse?

• A. Telling the client everything about their disease, what will happen in the course of the disease, and the outcome.
• B. Giving information to the client that is accurate and understandable.
• C. Informing the client that the pain they experience might not be real.
• D. Administering medication to the client when they experience pain.

Correct answer: B

Rationale: Client education by the nurse involves providing accurate and understandable information to the client. It is essential to offer relevant details without overwhelming them, making choice B the correct answer. Choice A is incorrect because providing excessive details can confuse the client rather than empower them with necessary knowledge. Choice C is incorrect as it is not the role of the nurse to question the reality of a client's pain; instead, they should address and manage the pain effectively. Choice D is incorrect as client education focuses on providing information and empowering clients with knowledge, not just administering medication.

3. Upon admission, the client expresses a desire for an extra oxygen tank in their room due to a previous breathing issue. What is the most appropriate response?

• A. "I will make sure there is always an extra oxygen tank in your room."?
• B. "I will ask the previous nurse if the extra tank was needed."?
• C. "I will need to check if your insurance benefits would cover an additional oxygen tank."?
• D. "The first priority is ensuring there are enough oxygen tanks for everyone who needs them. I am not sure we will be able to provide an extra on standby."?

Correct answer: D

Rationale: The appropriate response in this situation is to prioritize the availability of oxygen tanks for all patients in need. While it is understandable that the client may desire an extra tank for reassurance, the healthcare facility must ensure equitable distribution based on clinical need. Option A is incorrect because promising an always available extra tank may not be feasible and can set unrealistic expectations. Option B is not the best response as it focuses on past actions rather than addressing the current situation. Option C is not the most appropriate response at this time as the client's immediate need for an extra oxygen tank is the primary concern. Therefore, the best response is to emphasize the importance of equitable distribution of resources while acknowledging the client's request for an extra tank.

4. A nurse in charge of a long-term care facility who is working with a nursing assistant on the night shift prepares to take a break. To ensure client safety during the break, which actions should the nurse take? Select all that apply.

• A. Asking the nursing assistant to contact the health care provider during the nurse’s break if a client’s pain medication is not effective
• B. Informing the nursing assistant that she is leaving the nursing unit to get a cup of coffee from a vending machine in the lobby
• C. Asking the nursing assistant to administer a medication placed at the client's bedside if the client awakens
• D. Conducting client rounds before taking the break

Correct answer: D

Rationale: The nurse is responsible for ensuring client safety at all times and must not leave the nursing unit for any reason during the shift. The nurse’s break should be taken in a designated area located on the nursing unit. Before taking the break, the nurse should check all clients to ensure that they are safe and comfortable and that their needs have been met. Conducting client rounds before taking the break is crucial to assess the clients' conditions and address any immediate needs, ensuring their safety. Asking the nursing assistant to contact the health care provider during the nurse’s break is not appropriate as the nurse should handle this responsibility. Leaving the nursing unit to get coffee is not recommended as the nurse should stay within the unit to respond promptly to any client needs. Asking the nursing assistant to administer medication or make clinical decisions is outside the scope of their practice and should not be delegated.

5. A client with a spinal cord injury is preparing to return home from the rehabilitation unit. Which of the following statements by a family member indicates a need for further teaching regarding autonomic dysreflexia?

• A. "I should raise him to a sitting position."?
• B. "I should check for a fecal impaction."?
• C. "I should look for a kink in the urinary catheter tubing."?
• D. "I should observe whether symptoms worsen."?

Correct answer: D

Rationale: If the client develops signs or symptoms of autonomic dysreflexia, they need to be addressed immediately. If the family member is not able to relieve them, a healthcare provider needs to be notified immediately. The statement 'I should observe whether symptoms worsen' indicates a passive approach and does not address the urgency of the situation. Choices A, B, and C are correct as they involve active measures to address autonomic dysreflexia, such as raising the client to a sitting position, checking for a fecal impaction, and looking for a kink in the urinary catheter tubing.

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