Nursing Elites

1. A policy requiring the removal of acrylic nails by all nursing personnel was implemented 6 months ago. Which assessment measure best determines if the intended outcome of the policy is being achieved?

• A. Number of staff-induced injuries
• B. Client satisfaction survey
• C. Healthcare-associated infection rate
• D. Rate of needle-stick injuries by nurses

Correct answer: C

Rationale: The correct answer is C - Healthcare-associated infection rate. Acrylic nails can harbor bacteria, increasing the risk of healthcare-associated infections. By implementing a policy to remove acrylic nails, the goal is to reduce the infection rate. Monitoring the healthcare-associated infection rate will provide a direct measure of the policy's effectiveness in achieving its intended outcome. This measure is more specific and directly related to the objective of reducing the risk of infections compared to the other choices.

2. The healthcare provider is providing passive range of motion (ROM) exercises to the hip and knee for a client who is unconscious. After supporting the client's knee with one hand, what action should the healthcare provider take next?

• A. Raise the bed to a comfortable working level.
• B. Bend the client's knee.
• C. Move the knee toward the chest as far as it will go.
• D. Cradle the client's heel.

Correct answer: D

Rationale: When providing passive ROM exercises to the hip and knee for an unconscious client, it is essential to support the joints of the knee and ankle. The next action should be to cradle the client's heel and gently move the limb in a slow, smooth, firm, but gentle manner. This helps maintain joint mobility and prevent contractures.

3. A client is receiving external radiation therapy for lung cancer. Which intervention is most important for the nurse to include in the client's plan of care?

• A. Encourage the client to use sunscreen when outdoors.
• B. Apply a heating pad to the radiation site.
• C. Instruct the client to avoid using deodorant on the skin near the radiation site.
• D. Advise the client to increase intake of green leafy vegetables.

Correct answer: C

Rationale: Instructing the client to avoid using deodorant on the skin near the radiation site (C) is crucial to prevent skin irritation and potential adverse reactions during external radiation therapy. Sunscreen (A), heating pad (B), and dietary changes (D) are less pertinent in this situation.

4. The healthcare provider assesses a 2-year-old who is admitted for dehydration and finds that the peripheral IV rate by gravity has slowed, even though the venous access site is healthy. What should the healthcare provider do next?

• A. Apply a warm compress proximal to the site.
• B. Check for kinks in the tubing and raise the IV pole.
• C. Adjust the tape that stabilizes the needle.
• D. Flush with normal saline and recount the drop rate.

Correct answer: B

Rationale: In this scenario, the appropriate next step for the healthcare provider is to check for kinks in the tubing and raise the IV pole. These issues can commonly cause a slowed IV rate. Applying a warm compress (Choice A) may not address the underlying problem of kinked tubing or incorrect IV pole height. Adjusting the tape that stabilizes the needle (Choice C) is important for securement but is not the priority in this situation. Flushing with normal saline and recounting the drop rate (Choice D) should only be done after ruling out mechanical issues like kinks in the tubing.

5. When a client has suffered severe burns all over his body, the most effective method of monitoring the cardiovascular system is:

• A. Cuff blood pressure.
• B. Arterial pressure.
• C. Pulmonary artery pressure.
• D. Central venous pressure.

Correct answer: D

Rationale: Central venous pressure (CVP) monitoring is the most effective method to assess fluid status and the cardiovascular system in a client with severe burns. Severe burns can lead to significant fluid shifts and hemodynamic changes, making central venous pressure monitoring crucial for guiding fluid resuscitation and managing cardiovascular stability in these patients.

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