Nursing Elites

1. The functional health pattern assessment data states: 'Eats three meals a day and is of normal weight for height.' The nurse should draw which of the following conclusions about this data? Select all that apply.

• A. Client has an actual health problem
• B. Client has a wellness diagnosis
• C. Collaborative health problem needs to be written
• D. Possible nursing diagnosis exists

Correct answer: B

Rationale: The assessment data provided indicates a healthy pattern of nutrition and a normal weight for height, suggesting a positive health status. This aligns with a wellness diagnosis, such as 'Potential for enhanced nutrition,' which focuses on improving health further. An actual health problem refers to a current health issue present in the client, which is not evident in this data. Collaborative health problems involve interprofessional collaboration and are not indicated based on the information provided. While a diet assessment may be needed to evaluate food quality, the initial data suggests a wellness-focused approach to care.

2. When a nurse's hand comes in contact with a client's blood after providing wound care, what is the next action the nurse should take?

• A. Use an alcohol-based hand sanitizer to disinfect the hands
• B. Wash hands with soap and water using appropriate technique
• C. Notify the appropriate personnel about the exposure to client's blood
• D. Sample some of the client's blood to determine the presence of diseases

Correct answer: B

Rationale: When a nurse's hand comes in contact with a client's blood, it is important to follow appropriate infection control measures. Using an alcohol-based hand sanitizer is not sufficient in this scenario as the blood is a visible contaminant. The best practice is to wash hands with soap and water using appropriate technique to ensure thorough cleansing and removal of any potential pathogens. Notifying the appropriate personnel about the exposure is important for documentation and further evaluation, but immediate hand hygiene is crucial. Sampling the client's blood for disease determination is not within the nurse's scope of practice and is unnecessary in this situation.

3. Digestion, elimination, and ___________ are the three functions of the digestive system.

• A. constriction
• B. relaxation
• C. absorption
• D. peristalsis

Correct answer: C

Rationale: The correct answer is 'absorption.' The three main functions of the digestive system are digestion, absorption, and elimination. Absorption refers to the process of absorbing nutrients and other substances from the digested food into the bloodstream. Choices A, B, and D are incorrect: Constriction is not a primary function of the digestive system, relaxation is not a distinct function in this context, and peristalsis is a muscular movement that aids in digestion but is not one of the three main functions of the digestive system.

4. The nurse is reviewing concepts related to one's heritage and beliefs. Which concept refers to an organized system of beliefs concerning the cause, nature, and purpose of the universe?

• A. Culture
• B. Religion
• C. Ethnicity
• D. Spirituality

Correct answer: B

Rationale: Religion refers to an organized system of beliefs concerning the cause, nature, and purpose of the universe, as well as the attendance of regular services. Religion is a shared experience of spirituality or the values, beliefs, and practices into which people are either born or that they may adopt to meet their personal spiritual needs through communal actions, such as religious affiliation, attendance and participation in a religious institution, prayer, or meditation, and religious practices. Culture is a complex phenomenon that includes attitudes, beliefs, self-definitions, norms, roles, and values learned from birth through the processes of language acquisition and socialization. It does not refer to a belief in a divine or superhuman power. Ethnicity pertains to a social group within the social system that claims to possess variable traits, such as a common geographic origin, religion, race, and others. Spirituality is a broad term focused on a connection with something bigger than oneself and a belief in transcendence.

5. To accurately assess a patient's respiration rate, which of the following methods would be BEST?

• A. Tell the patient, 'Please remain silent while I count your number of breaths.'
• B. Count respirations at the same time you are counting the pulse rate
• C. Count the pulse rate for one minute, then, while keeping your index fingers on the patient's radial artery, count the respirations for an additional minute.
• D. Count the patient's respiration rate, then take the patient's temperature, and then take the pulse rate.

Correct answer: B

Rationale: The most accurate method to assess a patient's respiration rate is to count the breaths simultaneously while counting the pulse rate. This approach ensures that the patient is unaware of the specific focus on their breathing, preventing any conscious alteration in breathing patterns. Choice A is incorrect because informing the patient may lead to altered breathing as the patient may consciously change their breathing pattern. Choice C involves counting the pulse rate first, which is not necessary for assessing respiration rate. Choice D is incorrect as it includes unnecessary steps such as taking the patient's temperature before counting respiration rate, which adds no value to accurately assessing the respiration rate.

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