Nursing Elites

1. A nursing instructor is observing a nursing student practicing standard precautions. Which observation by the instructor indicates a need for further teaching?

• A. The nursing student wears a gown to change the bed of an incontinent client.
• B. The nursing student washes hands before making contact with the client.
• C. The nursing student washes her hands before glove removal after emptying a Foley bag.
• D. The nursing student changes gloves between tasks and procedures.

Correct answer: C

Rationale: The correct answer is C. The nursing student washing her hands before glove removal after emptying a Foley bag indicates a need for further teaching. Hands should be washed after glove removal to maintain proper infection control. Choice A is correct as wearing a gown when changing the bed of an incontinent client is a standard precaution. Choice B is correct as washing hands before making contact with the client is a good practice. Choice D is correct as changing gloves between tasks and procedures is a standard precaution to prevent the spread of infection.

2. What is the priority when assessing a patient for possible deep vein thrombosis (DVT)?

• A. Dorsiflex the foot and check for pain.
• B. Measure the calf circumference of both legs.
• C. Check the skin for signs of redness.
• D. Perform a Doppler ultrasound scan.

Correct answer: B

Rationale: The correct answer is to measure the calf circumference of both legs when assessing a patient for possible DVT. An increase in calf circumference in one leg can indicate the presence of a DVT. Option A is incorrect because dorsiflexing the foot and checking for pain are not primary assessments for DVT. Option C is incorrect as redness of the skin may not always be present in cases of DVT. Option D is incorrect as performing a Doppler ultrasound scan is usually done after clinical assessment and to confirm the diagnosis, not as the initial priority assessment.

3. A charge nurse is discussing HIPAA with a newly licensed nurse. Which of the following actions should the charge nurse include in the teaching as an example of a HIPAA violation?

• A. Posting the name of the nurse providing care on a client's communication board
• B. Discussing the client's new medication with a hospital pharmacist
• C. Faxing requested medical information for a client who is transferring to another facility
• D. Emailing the client's positive hepatitis results from an unencrypted server

Correct answer: D

Rationale: The correct answer is D. Emailing client information through an unencrypted server is a HIPAA violation because it can lead to data breaches. Choices A, B, and C do not violate HIPAA. Posting the name of the nurse providing care on a client's communication board does not disclose sensitive health information. Discussing the client's new medication with a hospital pharmacist is a routine healthcare practice. Faxing requested medical information for a client who is transferring to another facility is a secure way to transmit healthcare data.

4. A nurse is caring for a client who has an indwelling urinary catheter and a prescription for a urine specimen for culture and sensitivity. Which of the following actions should the nurse take?

• A. Wipe the area around the needleless port with sterile water
• B. Insert the syringe into the needleless port at a 60-degree angle
• C. Withdraw 3 to 5 ml of urine from the port
• D. Don sterile gloves

Correct answer: C

Rationale: The correct action for the nurse to take is to withdraw 3 to 5 ml of urine from the port for an accurate culture and sensitivity test. Wiping the area around the needleless port with sterile water (Choice A) is not necessary when obtaining a urine specimen. Inserting the syringe into the needleless port at a 60-degree angle (Choice B) is incorrect as it does not align with the correct procedure for obtaining a urine specimen. Donning sterile gloves (Choice D) is a good practice but not the immediate action required for obtaining a urine specimen.

5. A nurse is monitoring a client following a thoracentesis. The nurse should identify which of the following manifestations as a complication and contact the provider immediately?

• A. Increased heart rate
• B. Decreased temperature
• C. Serosanguineous drainage from the puncture site
• D. Discomfort at the puncture site

Correct answer: A

Rationale: Correct Answer: A nurse should identify an increased heart rate as a complication following a thoracentesis and contact the provider immediately. An increased heart rate may indicate a pneumothorax or other serious complications. Choices B, C, and D are incorrect because decreased temperature, serosanguineous drainage, and discomfort at the puncture site are expected findings following a thoracentesis and do not indicate a significant complication requiring immediate provider notification.

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