Nursing Elites

1. How many feet should separate the nurse and the source when extinguishing a small, wastebasket fire with an appropriate extinguisher?

• A. 1 foot
• B. 2 feet
• C. 4 feet
• D. 6 feet

Correct answer: D

Rationale: The nurse should stand about 6 feet from the source of the fire. Getting closer might put the nurse in danger. Choice A, 1 foot, is incorrect because it is too close to the fire and can expose the nurse to unnecessary risk. Choice B, 2 feet, is also too close to the fire and may lead to potential harm. Similarly, choice C, 4 feet, is not the ideal distance as it is still within the range of potential danger. The correct answer is D, 6 feet, which is a safe distance for the nurse to extinguish the fire effectively without risking personal safety.

2. The nurse is preparing task assignments for the day. Which task should the nurse assign to a nursing assistant?

• A. Monitoring for bleeding for a client who has just undergone cardiac catheterization
• B. Assisting a client who is getting up to ambulate for the first time after surgery
• C. Providing oral care to an unconscious client who requires oral care
• D. Completing the preoperative checklist for a client scheduled for a liver biopsy

Correct answer: C

Rationale: When delegating tasks, the nurse must consider the state nursing practice act guidelines and job descriptions. Providing oral care to an unconscious client is a task suitable for delegation to a nursing assistant. The nurse should give clear instructions on adapting the procedure for the client's needs and the signs of complications to watch for. Monitoring for bleeding after cardiac catheterization necessitates immediate nursing assessment, which requires critical thinking and intervention that exceeds a nursing assistant's scope of practice. Assisting a client with ambulation post-surgery carries the risk of orthostatic hypotension and should be performed by a licensed nurse. Completing a preoperative checklist for a client scheduled for a liver biopsy involves critical assessment and preparation that are within the nurse's scope of practice.

3. A nurse witnesses a client sign the consent form for surgery with the surgeon. As the surgeon leaves, the client starts to speak and then stops. The nurse asks if the client has further questions, and he says, "I don't want to bother the surgeon."? The nurse should ____.

• A. acknowledge the client's wish not to bother the surgeon and tell the client to let you know if they change their mind
• B. acknowledge the client's wish not to bother the surgeon and answer all of their questions, as appropriate
• C. go get the surgeon to answer all of the client's questions
• D. answer any questions as appropriate as well as have the surgeon come back to answer any questions if needed

Correct answer: D

Rationale: In this scenario, the nurse should prioritize the client's understanding and comfort. While acknowledging the client's wish not to bother the surgeon is important, it is equally crucial to ensure that the client's questions are answered appropriately and thoroughly. Choice A is correct as it respects the client's initial sentiment and offers the client the opportunity to ask questions later if needed. Choice B is incorrect as it suggests answering all questions immediately, without considering the client's feelings. Choice C is incorrect as it bypasses the nurse's role in addressing the client's concerns. Choice D, the correct answer, balances respecting the client's wish and ensuring that all questions are appropriately addressed, even if it involves the surgeon returning.

4. The nurse acts as an advocate for the nursing profession by performing all of the following activities except:

• A. encouraging political involvement by nurses with their legislators.
• B. acting as a first-aid provider for a children's athletic team.
• C. precepting newly licensed nurses in the work situation.
• D. encouraging as many persons to become nurses as possible.

Correct answer: D

Rationale: The nurse acts as an advocate for the nursing profession by encouraging appropriate persons to become nurses, by being a positive role model and mentor, and by communicating the needs of nurses in the most professional manner possible to those making the laws. Encouraging as many persons as possible to become nurses may not align with the advocacy role, as the focus should be on quality rather than quantity. Choices A, B, and C are activities that align with being an advocate for the nursing profession by promoting political involvement, providing first aid, and precepting newly licensed nurses, respectively.

5. A client with a left arm fracture complains of severe diffuse pain that is unrelieved by pain medication. On further assessment, the nurse notes that the client experiences increased pain during passive motion compared with active motion of the left arm. Based on these assessment findings, which action should the nurse take first?

• A. Contacting the health care provider
• B. Checking if it is time for more pain medication
• C. Encouraging the client to continue active range of motion exercises of the left arm
• D. Repositioning the client for comfort

Correct answer: A

Rationale: The correct answer is to contact the health care provider. The client with early acute compartment syndrome typically complains of severe diffuse pain that is unrelieved by pain medication. Additionally, the affected client experiences greater pain during passive motion compared to active motion. In this situation, it is crucial to notify the health care provider immediately for further evaluation and intervention. Contacting the health care provider is essential to ensure timely diagnosis and appropriate management of the condition. Checking for more pain medication, encouraging active range of motion exercises, or repositioning the client may not address the underlying issue of acute compartment syndrome and could delay necessary interventions. Therefore, the priority action should be to involve the healthcare provider for prompt assessment and treatment.

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