Nursing Elites

1. A patient's urine specimen tested positive for bilirubin. Which of the following is most true?

• A. The patient should be evaluated for kidney disease
• B. The specimen was probably left at room temperature for more than two hours
• C. The specimen is positive for bacteria
• D. The specimen should be stored in an area protected from light

Correct answer: D

Rationale: Bilirubin is easily broken down by light, so all samples testing positive for bilirubin should be protected from light exposure. Storing the specimen in an area protected from light helps maintain the integrity of the bilirubin levels for accurate testing. Choice A is incorrect because the presence of bilirubin in urine does not necessarily indicate kidney disease. Choice B is incorrect as the exposure to light, not room temperature, affects bilirubin levels. Choice C is incorrect as the presence of bilirubin does not indicate the presence of bacteria in the specimen.

2. A client on the nursing unit is terminally ill but remains alert and oriented. Three days after admission, the nurse observes signs of depression. The client states, 'I'm tired of being sick. I wish I could end it all.' What is the most accurate and informative way to record this data in a nursing progress note?

• A. Client appears to be depressed, possibly suicidal
• B. Client reports being tired of being ill and wants to die
• C. Client does not want to live any longer and is tired of being ill
• D. Client states, 'I'm tired of being sick. I wish I could end it all.'

Correct answer: D

Rationale: Subjective data includes thoughts, beliefs, feelings, perceptions, and sensations that are apparent only to the person affected and cannot be measured, seen, or felt by the nurse. This information should be documented using the client's exact words in quotes. The other options indicate that the nurse has drawn the conclusion that the client no longer wishes to live. From the data provided, the cues do not support this assumption. A more complete assessment should be conducted to determine if the client is suicidal.

3. As a valued member of the team on your nursing care unit, you are trying to determine whether the team is doing well. Which of the following is a sign that your team is successful?

• A. Conflict occurs but is seen as an opportunity for team growth and development.
• B. No negative feelings are expressed, leading to everyone being happy and satisfied.
• C. Mistakes are not tolerated and result in disciplinary action.
• D. People avoid taking risks and stick to the status quo.

Correct answer: A

Rationale: One of the key indicators of a successful team is the ability to handle conflict positively. Conflict, when managed well, can lead to team growth and development. Choice B is incorrect because suppressing negative feelings does not indicate team success; open communication is crucial. Choice C is incorrect as successful teams view mistakes as learning opportunities rather than resorting to disciplinary action. Choice D is incorrect because successful teams are often innovative and willing to take risks rather than maintaining the status quo.

4. The nurse informs the physical therapy department that the client is too weak to use a walker and needs to be transported by wheelchair. Which step of the nursing process is the nurse engaged in at this time?

• A. Assessment
• B. Planning
• C. Implementation
• D. Evaluation

Correct answer: C

Rationale: The nurse is responsible for coordinating the plan of care with other disciplines to ensure the client's safety. This action represents the implementation phase of the nursing process. During the implementation phase, the nurse puts the care plan into action, which includes coordinating with other healthcare team members like the physical therapy department. Assessment involves data gathering, planning involves goal setting, and evaluation involves determining the attainment of client goals.

5. Which is the most effective action for controlling the spread of infection?

• A. Thorough hand hygiene
• B. Wearing gloves and masks when providing direct client care
• C. Implementing appropriate isolation precautions
• D. Administering broad-spectrum prophylactic antibiotics

Correct answer: A

Rationale: Thorough hand hygiene is the most effective action for controlling the spread of infection as hands are a common source of transmission. Regular and routine hand hygiene helps prevent the movement of potentially infective materials. Wearing gloves and masks is important when providing direct client care to protect both the caregiver and the patient, but it is not as effective as thorough hand hygiene in preventing overall infection spread. Implementing appropriate isolation precautions is necessary for clients with known communicable diseases, but it is not as universally effective in preventing the spread of various infections. Administering broad-spectrum prophylactic antibiotics is not an appropriate measure for controlling the spread of infection as routine use can lead to superinfection and the development of resistant organisms.

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