Nursing Elites

1. A student is late for an appointment and has rushed across campus to the health clinic. How should the nurse proceed?

• A. Allow 5 minutes for the student to relax and rest before checking their vital signs.
• B. Check the blood pressure in both arms, expecting a difference in the readings due to the recent exercise.
• C. Immediately monitor the student's vital signs upon arrival at the clinic and then 5 minutes later, recording any differences.
• D. Check the student's blood pressure in the supine position to provide a more accurate reading and allow the student to relax at the same time.

Correct answer: A

Rationale: To ensure an accurate blood pressure reading, it is important for the student to be in a relaxed state. Allowing at least a 5-minute rest period helps reduce anxiety and provides a valid blood pressure measurement. Checking the blood pressure in both arms is unnecessary unless there is a specific reason to suspect an issue, and recent exercise should not significantly impact the readings. Monitoring vital signs immediately upon arrival may not yield accurate results due to the rush and anxiety of the student. Checking blood pressure in the supine position is not necessary in this scenario and does not provide a more accurate reading.

2. A nurse caring for a client diagnosed with pertussis is ordered to maintain droplet precautions. Which of the following actions of the nurse upholds droplet precautions?

• A. Assign the client to stay in a negative-pressure room
• B. Use sterilized equipment when sharing between this client and another person with pertussis
• C. Wear a mask if coming within 3 feet of the client
• D. Both A and C

Correct answer: C

Rationale: When caring for a client requiring droplet precautions, it is essential for the nurse to wear a mask when within 3 feet of the client. This practice helps prevent the transmission of droplet particles that may be produced when the client coughs or sneezes. Assigning the client to a negative-pressure room is not typically necessary for droplet precautions unless specifically indicated for airborne precautions. Using sterilized equipment when sharing between clients with pertussis is important for infection control but does not directly relate to droplet precautions. Therefore, the correct action to uphold droplet precautions in this scenario is to wear a mask when coming within close proximity to the client.

3. A 75-year-old client, hospitalized with a cerebral vascular accident (stroke), becomes disoriented at times and tries to get out of bed but is unable to ambulate without help. What is the most appropriate safety measure?

• A. Restrain the client in bed
• B. Ask a family member to stay with the client
• C. Check the client every 15 minutes
• D. Use a bed exit safety monitoring device

Correct answer: D

Rationale: Option D is the most appropriate safety measure in this scenario. Using a bed exit safety monitoring device allows the client to retain some independence while ensuring that the nursing staff is alerted when assistance is needed. This solution promotes client safety without compromising their autonomy. Option A, restraining the client in bed, can lead to increased agitation, confusion, and a loss of independence. Option B, asking a family member to stay with the client, shifts the responsibility away from the healthcare team. Option C, checking the client every 15 minutes, is not a sufficient safety measure as the client could attempt to get out of bed in the unobserved interval, risking falls and injury.

4. What would be an appropriate evaluation statement for the nurse to write based on the client's ability to state only two signs of impaired circulation out of three as expected?

• A. Client understands the signs of impaired circulation
• B. Goal met: Client cited numbness and tingling as a sign of impaired circulation
• C. Goal not met: Client able to name only two signs of impaired circulation
• D. Goal not met: Client unable to describe signs of impaired circulation

Correct answer: C

Rationale: The appropriate evaluation statement for the nurse to write would be 'Goal not met: Client able to name only two signs of impaired circulation.' In this scenario, the client has only identified two out of the three signs of impaired circulation specified in the desired outcome. Therefore, the goal has not been fully achieved. It is essential in nursing practice to assess and document client progress accurately. While the client has shown some understanding by correctly identifying numbness and tingling as signs of impaired circulation, the inability to state the third sign indicates an incomplete achievement of the goal. This evaluation helps guide further interventions or educational strategies to help the client meet the desired outcome in the care plan.

5. When placing a patient in the AP position for an X-ray, what position would the patient be in?

• A. Facing the X-ray film.
• B. Right side against the X-ray film.
• C. Left side against the X-ray film.
• D. Facing away from the X-ray film

Correct answer: D

Rationale: The AP position stands for Anteroposterior Projection. When a patient is in the AP position for an X-ray, they are facing away from the X-ray film. This positioning allows for a clear view of the structures being imaged from front to back. Choices A, B, and C are incorrect because the patient is not facing or positioned against the X-ray film in the AP position, but rather facing away from it to capture the necessary diagnostic information.

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