Nursing Elites

1. An assistive personnel says to the nurse, “This client is incontinent of stool three or four times a day. I get angry, and I think that the client is doing it just to get attention. I think we should put adult diapers on her.” Which is the appropriate nursing response?

• A. You should report this to the supervisor
• B. It is very upsetting to see an adult client regress
• C. Diapers are the best solution
• D. The client’s condition is not your concern

Correct answer: B

Rationale: The correct response is 'It is very upsetting to see an adult client regress.' In this situation, the nurse should acknowledge the emotional impact of caregiving on the assistive personnel and address it professionally. Choice A is incorrect because reporting to the supervisor may not directly address the emotional concerns raised. Choice C is incorrect because immediately resorting to diapers without further assessment or intervention is not the most appropriate solution. Choice D is incorrect as the client's well-being and care are a shared responsibility among healthcare team members.

2. While interviewing a client, the nurse records the assessment in the electronic health record. Which statement is most accurate regarding electronic documentation during an interview?

• A. The client's comfort level is increased when the nurse maintains eye contact while typing notes into the record
• B. The interview process is hindered by electronic documentation and may disrupt the flow of conversation
• C. The nurse has limited ability to observe nonverbal communication while entering the assessment electronically
• D. Completing the electronic record during an interview is optional and not a legal obligation of the examining nurse

Correct answer: C

Rationale: The most accurate statement is that the nurse has a limited ability to observe nonverbal communication while entering the assessment electronically. This is because the nurse's focus is on typing or inputting data, which may lead to missing important nonverbal cues from the client. Choices A and B are incorrect as they do not address the limitation of observing nonverbal cues. Choice A is incorrect because breaking eye contact to type notes may hinder the client's comfort level. Choice B is incorrect because it states that electronic documentation enhances the interview process, which may not always be the case. Choice D is incorrect as completing the electronic record during an interview is typically a standard practice but not a legal obligation.

3. During passive range of motion (ROM) exercises, how should the nurse perform each movement for a patient with impaired mobility?

• A. The nurse moves each movement just to the point of resistance.
• B. The patient repeats each movement 5 times.
• C. The movement continues until the patient reports pain.
• D. The nurse completes each movement quickly and smoothly.

Correct answer: A

Rationale: During passive range of motion (ROM) exercises, the nurse is responsible for moving the patient's joints through their range of motion. The correct technique involves performing movements slowly and smoothly, only going to the point of resistance without causing pain. This technique helps maintain joint flexibility and prevent contractures. Choice A is the correct answer as it reflects the appropriate technique for passive ROM exercises. Choices B and C are incorrect because the patient is not actively participating, and ROM exercises should not cause pain. Choice D is incorrect as movements should be done deliberately and not quickly.

4. A client will require oxygen therapy at home. Which of the following statements should the nurse identify as an indication that the client understands how to manage this therapy at home?

• A. I'll make sure that, when my friend comes by, they smoke at least 6 feet away from my oxygen tank.
• B. I'll use a cotton blanket if I get chilly while I'm using my oxygen.
• C. I'll check the wires and cables on my oxygen equipment to make sure they are in good working order.
• D. I'll secure my oxygen tank in an upright position to prevent it from being knocked over.

Correct answer: C

Rationale: The correct answer is C. Ensuring the oxygen equipment's wires and cables are in good working order is crucial to prevent sparks in an oxygen-rich environment, which could lead to a fire. Choices A, B, and D are incorrect because smoking near an oxygen tank, using a cotton blanket near oxygen (as cotton is less likely to generate static electricity than wool), and laying the oxygen tank down on the floor pose significant safety risks and are not appropriate practices for managing oxygen therapy at home.

5. A nurse is in a public building when someone cries out, 'Help! I think he is having a heart attack!' The nurse responds to the scene and finds the unconscious adult lying on the floor. Another bystander has obtained an AED. The nurse's first action, after ensuring someone has called for EMS, should be to:

• A. Administer cardiac compressions
• B. Attach the AED pads to the client
• C. Check for a pulse
• D. Perform rescue breaths

Correct answer: A

Rationale: In a scenario where a person is unconscious and there is an indication of a possible heart attack, the immediate priority for the nurse should be to administer cardiac compressions. This action helps maintain circulation and ensures oxygenated blood reaches vital organs until the AED is available. Checking for a pulse or performing rescue breaths may delay essential circulation support, and attaching AED pads should follow the initial step of administering compressions to maximize the chances of a successful resuscitation.

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