Nursing Elites

1. A school nurse is providing care for students in an elementary education facility. Which of the following interventions by the nurse addresses the primary level of prevention?

• A. Design interventions for a student's individual education plan (IEP).
• B. Teach students about healthy food choices.
• C. Perform first aid for minor injuries.
• D. Perform scoliosis screenings for students.

Correct answer: B

Rationale: The correct answer is B because teaching students about healthy food choices is a primary prevention strategy that aims to prevent future health issues by promoting healthy behaviors. Choice A, designing interventions for an individual education plan (IEP), is more related to addressing specific educational needs rather than preventing health issues. Choice C, performing first aid for minor injuries, is a form of secondary prevention aimed at reducing the impact of existing health problems. Choice D, performing scoliosis screenings for students, falls under secondary prevention by detecting health issues early rather than preventing them.

2. A patient is admitted with signs of stroke. Which of the following diagnostic tests should the nurse anticipate as the priority?

• A. CT scan
• B. MRI
• C. X-ray
• D. Ultrasound

Correct answer: A

Rationale: A CT scan is the priority diagnostic test to identify and confirm the location and severity of a stroke.

3. A charge nurse is planning care for a group of clients on a medical-surgical unit. Which of the following tasks should the nurse delegate to an assistive personnel (AP)?

• A. Giving a glycerin suppository to a client for constipation
• B. Evaluating the effectiveness of ibuprofen administered to a client who reported a headache
• C. Discussing dietary changes with a client who has a prescription for a gluten-free diet
• D. Measuring hourly urinary output for a client who is postoperative

Correct answer: D

Rationale: The correct answer is D because measuring hourly urinary output is a task that falls within the scope of practice for assistive personnel. This task involves a technical skill that can be delegated by the charge nurse. Choices A, B, and C require higher-level nursing assessments and interventions that should be performed by licensed nursing staff. Giving a glycerin suppository involves medication administration, evaluating the effectiveness of ibuprofen requires assessment and critical thinking, and discussing dietary changes involves education and assessment of the client's understanding and compliance, all of which are beyond the scope of practice for assistive personnel.

4. Which intervention reduces reservoirs of infection in a healthcare setting?

• A. Placing capped needles and syringes in puncture-resistant containers
• B. Keeping bedside table surfaces clean and dry
• C. Changing dressings that become wet or soiled
• D. Placing tissues and soiled dressings in paper bags

Correct answer: A

Rationale: Placing capped needles and syringes in puncture-resistant containers is the correct intervention to reduce infection reservoirs in healthcare settings. This practice helps prevent accidental needle-stick injuries and contains potentially infectious materials properly. Keeping bedside table surfaces clean and dry (choice B) is essential for preventing the spread of infections but does not directly address reducing reservoirs of infection. Changing dressings that become wet or soiled (choice C) is important for wound care but does not specifically target infection reservoirs. Placing tissues and soiled dressings in paper bags (choice D) is a proper waste disposal practice but does not directly reduce reservoirs of infection in a healthcare setting.

5. A patient has an ankle restraint applied. Upon assessment, the nurse finds the toes a light blue color. Which action will the nurse take next?

• A. Immediately do a complete head-to-toe neurological assessment.
• B. Take the patient's blood pressure, pulse, temperature, and respiratory rate.
• C. Place a blanket over the feet.
• D. Remove the restraint.

Correct answer: D

Rationale: The correct answer is to remove the restraint (Choice D). Cyanosis of the toes, indicated by a light blue color, suggests impaired circulation. The priority action is to ensure proper circulation by removing the restraint to prevent further compromise. Choices A and B are not the immediate actions needed for cyanosis related to impaired circulation. Choice C, placing a blanket over the feet, does not address the underlying issue of impaired circulation and could delay appropriate intervention.

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