Nursing Elites

1. A violation of a patient's confidentiality occurs if two nurses are discussing client information in which of the following scenarios?

• A. With a physical therapist treating the patient
• B. With a social worker planning for discharge
• C. With another nurse on duty to plan for break time
• D. In the hallway outside the patient's room

Correct answer: D

Rationale: The correct answer is 'In the hallway outside the patient's room.' Discussing client information in a public area like a hallway can potentially breach patient confidentiality as it increases the risk of unauthorized individuals overhearing sensitive information. Choices A, B, and C involve discussing client information with other healthcare professionals in appropriate settings, which are more likely to maintain patient confidentiality compared to discussing in a public space like a hallway. Option D is the correct choice because it highlights a scenario where patient information is at higher risk of exposure to unauthorized individuals, hence violating patient confidentiality.

2. Which of the following should be included in a diet rich in iron?

• A. peaches, eggs, beef
• B. cereals, kale, cheese
• C. red beans, enriched breads, squash
• D. legumes, green beans, eggs

Correct answer: A

Rationale: The correct answer is peaches, eggs, beef. These are good sources of heme iron, which is more easily absorbed by the body compared to nonheme iron. Heme iron is mainly found in animal-based foods like meat, poultry, and fish. Peaches, eggs, and beef are rich in iron and can help prevent iron deficiency anemia. Choices B, C, and D are incorrect because they do not include significant sources of heme iron. Cereals, kale, cheese, red beans, enriched breads, squash, legumes, and green beans are sources of nonheme iron, which is not as efficiently absorbed by the body as heme iron. It is important to include heme iron sources in the diet for optimal iron absorption.

3. Why must the nurse be careful not to cut through or disrupt any tears, holes, bloodstains, or dirt present on the clothing of a client who has experienced trauma?

• A. The clothing may be potential evidence with legal implications.
• B. Such care facilitates the preservation of potential evidence.
• C. The clothing of a trauma victim can be used for further investigation.
• D. Such care maintains the integrity of the clothing for forensic analysis.

Correct answer: C

Rationale: In cases of trauma, the clothing of a client can hold crucial evidence that may have legal implications. It is essential for the nurse to avoid cutting through or disrupting any tears, holes, bloodstains, or dirt present on the clothing to preserve this potential evidence. The correct answer highlights the legal importance of preserving the clothing for potential legal implications. Choice B is related but does not emphasize the legal aspect explicitly. Choice C is vague in mentioning further investigation without specifying the legal significance. Choice D focuses more on forensic analysis rather than the legal implications of preserving the clothing.

4. What do the following ABG values indicate: pH 7.38, PO2 78 mmHg, PCO2 36 mmHg, and HCO3 24 mEq/L?

• A. metabolic alkalosis
• B. homeostasis
• C. respiratory acidosis
• D. respiratory alkalosis

Correct answer: B

Rationale: The correct answer is 'homeostasis.' These ABG values fall within the normal range, indicating a state of balance and homeostasis. The pH is within the normal range (7.35-7.45), the PCO2 is normal (35-45 mmHg), and the HCO3 level is also normal (22-26 mEq/L). Choice A, 'metabolic alkalosis,' is incorrect because the pH, PCO2, and HCO3 levels are not indicative of metabolic alkalosis. Choice C, 'respiratory acidosis,' is incorrect as the pH and PCO2 values are not elevated. Choice D, 'respiratory alkalosis,' is incorrect as the pH and PCO2 levels are not decreased. Therefore, the ABG values provided do not correspond to any acid-base disturbance, confirming that the patient is in a state of homeostasis.

5. A nurse is returning phone calls in a pediatric clinic. Which of the following reports most requires the nurse's immediate attention and phone call?

• A. An 8-year-old boy has been vomiting, appears to have slower movements, and has a history of an atrioventricular shunt placement.
• B. A 10-year-old girl feels a dull pain in her abdomen after doing sit-ups in gym class.
• C. A 7-year-old boy has been having a low fever and headache for the past 3 days and has a history of an anterior knee wound.
• D. A 7-year-old girl who had a cast on her right ankle is complaining of itching.

Correct answer: A

Rationale: The correct answer is the 8-year-old boy with vomiting, slower movements, and a history of an atrioventricular shunt placement. This report requires immediate attention because the symptoms could indicate a blocked shunt, which is a serious medical condition needing urgent evaluation and intervention. Slower movements in the context of an atrioventricular shunt history could suggest increased intracranial pressure. The other choices involve less urgent issues: choice B describes post-exercise pain, choice C presents with a low-grade fever and headache that could be due to a mild infection, and choice D reports itching associated with a cast, which is a common issue and less critical compared to a potentially blocked shunt.

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