Nursing Elites

1. In a disaster triage situation, which of the following should the nurse be least concerned with regarding a client in crisis?

• A. ability to breathe
• B. pallor or cyanosis of the skin
• C. number of accompanying family members
• D. motor function

Correct answer: C

Rationale: During a disaster triage situation where quick decisions are crucial, the nurse's primary focus should be on factors directly related to the patient's immediate condition and survival. The ability to breathe, pallor or cyanosis of the skin, and motor function are critical indicators of a patient's health status and need for urgent intervention. In contrast, the number of accompanying family members, although important for emotional support, is not a priority when assessing and prioritizing care during a crisis. While emotional support is valuable, the focus in triage is on identifying and addressing the most critical and life-threatening issues first to maximize survival chances. Therefore, the nurse should be least concerned with the number of accompanying family members as it does not directly impact the patient's immediate medical needs in a crisis situation. Choices A, B, and D are all crucial factors to assess a client's health status and determine the urgency of intervention during a disaster triage. The ability to breathe indicates respiratory function, pallor or cyanosis of the skin reflect circulatory and oxygenation status, and motor function can hint at neurological impairment or injury, all of which are vital in determining the severity of the crisis and the immediate medical needs of the patient.

2. An 80-year-old aphasic CVA client had abdominal surgery 2 days ago. Which of the following puts this client at the highest risk for inadequate pain management?

• A. Inability to turn, cough, and breathe deeply
• B. Inability to communicate pain
• C. Inability to ambulate freely
• D. Inability to use a bedside commode

Correct answer: B

Rationale: The correct answer is B: Inability to communicate pain. In this scenario, the client's aphasia prevents them from verbally expressing their pain, which can lead to inadequate pain management if the healthcare team is not vigilant. The nurse must use alternative methods to assess and address the client's pain. Choices A, C, and D, although important considerations in postoperative care, do not directly relate to the client's ability to communicate pain, which is crucial for effective pain management in this case.

3. A nurse is supervising a new nursing graduate in various procedures. Which action by the new nursing graduate constitutes a negligent act?

• A. Giving a verbal report to the nurse on the oncoming shift
• B. Checking neurological signs in a client with a head injury
• C. Contacting a healthcare provider about a change in a client's blood pressure
• D. Using clean gloves to change a gastrostomy tube dressing

Correct answer: D

Rationale: Negligent acts in nursing include various errors that can harm the client, such as medication errors, intravenous therapy errors, burns, falls, failure to use aseptic technique, failure to provide adequate monitoring, and failure to report significant changes in a client's condition. In this scenario, using clean gloves to change a gastrostomy tube dressing is a negligent act because sterile gloves should be used when changing a dressing over broken skin. Choices A, B, and C are not negligent acts as they involve appropriate nursing actions: giving a verbal report, checking neurological signs, and contacting a healthcare provider about a change in a client's blood pressure.

4. A nurse is preparing for the admission of a client with pulmonary tuberculosis. Which action reflects the use of evidence-based practice in the care of the client?

• A. Keeping the door to the client's room closed
• B. Fitting the client for an N95 or HEPA (high-efficiency particulate air) mask to be worn at all times
• C. Placing the client in a semiprivate room with a cohort client
• D. Using a surgical mask when entering the client's room

Correct answer: A

Rationale: Evidence-based practice is an approach to client care that integrates the client's preferences, clinical expertise, and the best research evidence to deliver quality care. In the case of pulmonary tuberculosis, which is transmitted through the airborne route, keeping the door to the client's room closed is crucial to prevent the spread of infection. Placing the client in a semiprivate room with a cohort client is not recommended for airborne precautions; a private room is required to prevent transmission. Fitting the client for an N95 or HEPA mask is essential for the nurse's protection when entering the room, not for the client to wear at all times. Using a surgical mask when entering the client's room is not sufficient for airborne precautions; an N95 or HEPA mask is necessary.

5. When a client with a major burn experiences body image disturbance, which of the following is an appropriate nursing intervention classification?

• A. grief work facilitation
• B. vital signs monitoring
• C. medication administration: skin
• D. anxiety reduction

Correct answer: A

Rationale: The correct answer is 'grief work facilitation' because it is a nursing intervention classification specifically designed to address disturbed body image in burn clients. The expected outcome of this intervention is grief resolution, which can help the client cope with the body image changes resulting from the burn. Choice B, 'vital signs monitoring,' is not the appropriate intervention for body image disturbance in burn clients. Vital signs monitoring is typically used for assessing physiological parameters like blood pressure, pulse rate, and temperature. Choice C, 'medication administration: skin,' is more focused on treating skin-related issues rather than addressing body image disturbance. It involves the administration of medications to promote skin healing and integrity. Choice D, 'anxiety reduction,' is aimed at managing anxiety in clients with major burns and is not specifically targeted at addressing body image disturbance. While anxiety may be a common emotional response to burns, the most appropriate intervention for body image disturbance in this scenario is 'grief work facilitation.'

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