Nursing Elites

1. Patients exhibiting signs of cyanosis will:

• A. show signs of hyperoxia.
• B. have increased O2 saturation.
• C. have blood levels of CO2 higher than O2 levels.
• D. None of the above.

Correct answer: C

Rationale: Cyanosis is a bluish discoloration of the skin and mucous membranes resulting from low blood oxygen levels. When a patient exhibits cyanosis, it indicates that their blood is poorly oxygenated, leading to a higher concentration of CO2 compared to oxygen. Options A and B are incorrect as cyanosis is associated with low oxygen levels, not hyperoxia or increased O2 saturation. Therefore, the correct answer is that patients exhibiting cyanosis will have blood levels of CO2 higher than O2 levels.

2. A healthcare professional is preparing to administer a dose of platelets to a client. Which of the following actions must the healthcare professional perform before giving the platelets?

• A. Start an IV of 0.9% Normal Saline to administer with the platelets
• B. Ensure the container with the platelets is intact and not damaged
• C. Verify the client's identity using two unique identifiers
• D. Check the client's chart to ensure no contraindications to platelet transfusion

Correct answer: B

Rationale: Before administering platelets, it is crucial to check the integrity of the container holding the blood product. An intact container ensures the sterility and safety of the platelets, minimizing the risk of contamination or infection. Option A is incorrect as administering platelets typically does not require starting a new IV line unless indicated for the specific patient. Option C is not the priority as verifying the client's identity can be done at any point during the administration process but is not specific to the platelet transfusion itself. Option D, checking the client's chart for antibiotic use, is not directly related to ensuring the safety of the blood product container.

3. The healthcare provider is reviewing theories of illness. The germ theory, which states that microscopic organisms such as bacteria and viruses are responsible for specific disease conditions, is a basic belief of which theory of illness?

• A. Holistic
• B. Biomedical
• C. Naturalistic
• D. Magicoreligious

Correct answer: B

Rationale: The correct answer is B: Biomedical. Among the biomedical explanations for disease is the germ theory, which states that microscopic organisms such as bacteria and viruses are responsible for specific disease conditions. The naturalistic or holistic perspective holds that the forces of nature must be kept in natural balance. The magicoreligious perspective holds that supernatural forces dominate and cause illness or health. Therefore, options A, C, and D are incorrect as they do not align with the germ theory explanation provided in the question.

4. The nurse is caring for a patient who has a right-sided chest tube after a right lower lobectomy. Which nursing action can the nurse delegate to the unlicensed assistive personnel (UAP)?

• A. Document the amount of drainage every eight hours
• B. Obtain samples of drainage for culture from the system
• C. Assess patient pain level associated with the chest tube
• D. Check the water-seal chamber for the correct fluid level

Correct answer: A

Rationale: The correct answer is to document the amount of drainage every eight hours. UAP education typically includes tasks related to documentation of intake and output. Obtaining samples of drainage for culture and assessing patient pain level are nursing responsibilities that require licensed nursing personnel's education and scope of practice. Checking the water-seal chamber for the correct fluid level also falls under the nursing role, as it involves monitoring and maintaining the chest tube system, which requires nursing knowledge and training.

5. Which of these statements is true regarding the use of Standard Precautions in the healthcare setting?

• A. Standard Precautions apply to all body fluids, except sweat.
• B. Alcohol-based hand rub should be used if hands are not visibly dirty.
• C. Standard Precautions are intended for use with all patients, regardless of their risk or presumed infection status.
• D. Standard Precautions are to be used only when non-intact skin, excretions containing visible blood, or expected contact with mucous membranes are present.

Correct answer: C

Rationale: Standard Precautions are designed to reduce the risk for transmission of microorganisms from both recognized and unrecognized sources. They are intended for use with all patients, regardless of their risk or presumed infection status. Standard Precautions apply to all body fluids, secretions, and excretions except sweat - whether or not they contain visible blood, non-intact skin, or mucous membranes. Hands should be washed with soap and water if visibly soiled with blood or body fluids. Alcohol-based hand rubs can be used if hands are not visibly soiled. Choice A is incorrect because Standard Precautions apply to all body fluids, secretions, and excretions except sweat. Choice B is incorrect because alcohol-based hand rub should be used when hands are not visibly dirty. Choice D is incorrect because Standard Precautions are not limited to situations involving non-intact skin, excretions with visible blood, or expected mucous membrane contact.

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