Nursing Elites

1. Before allowing the client's infant granddaughter to visit before the client's scheduled heart transplant, the nurse decides it would be beneficial to collaborate with which of the following? Select all that apply.

• A. Client and Family
• B. Other nursing staff on the unit
• C. Security department
• D. Hospital administration

Correct answer: B

Rationale: Collaborating with the client and family is crucial as it fosters a sense of autonomy and active involvement in the healthcare process for the client. Involving other nursing staff ensures the successful implementation of the planned intervention and provides support for the client's needs. Collaboration with the security department or hospital administration is not necessary in this situation, as the focus should be on the client's well-being and family involvement during a sensitive time.

2. When assessing a 75-year-old patient who has asthma, the nurse notes that the patient assumes a tripod position, leaning forward with arms braced on the chair. How would the nurse interpret these findings?

• A. Interpret that the patient is eager and interested in participating in the interview.
• B. Evaluate the patient for abdominal pain, which may be exacerbated in the sitting position.
• C. Interpret that the patient is having difficulty breathing and assist them to a supine position.
• D. Recognize that a tripod position is often used when a patient is having respiratory difficulties.

Correct answer: D

Rationale: Assuming a tripod position"?leaning forward with arms braced on chair arms"?occurs with chronic pulmonary diseases like asthma. This position helps improve breathing by allowing better use of respiratory muscles. Option A is incorrect because assuming the tripod position is not related to being eager or interested in participating in an interview. Option B is incorrect as abdominal pain is not typically associated with the tripod position in this context. Option C is incorrect as assisting the patient to a supine position would not address the underlying respiratory difficulty indicated by the tripod position. Therefore, the correct interpretation is to recognize that the patient is likely experiencing respiratory difficulties when assuming the tripod position.

3. Who is legally able to make decisions for the patient or resident during a patient care conference when the patient is not mentally able to make decisions on their own?

• A. The patient or their healthcare proxy
• B. Only the patient
• C. Only the healthcare proxy
• D. The doctor

Correct answer: C

Rationale: When a patient is unable to make decisions due to mental incapacity, the healthcare proxy, designated by the patient in advance, has the legal authority to make decisions on the patient's behalf. In this situation, the patient lacks the capacity to make decisions independently. The healthcare proxy's role is to represent the patient's wishes and best interests. The doctor's role in a patient care conference is to provide medical expertise, offer recommendations, and assist in the decision-making process, but the final decision-making authority lies with the healthcare proxy, not the doctor.

4. 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.

5. The nurse is conducting a health fair for older adults. Which statement is true regarding vital sign measurements in aging adults?

• A. The pulse is easier to palpate due to the rigidity of the blood vessels.
• B. An increased respiratory rate and a shallower inspiratory phase are expected findings.
• C. A widened pulse pressure occurs from changes in the systolic and diastolic blood pressures.
• D. Changes in the body's temperature regulatory mechanism decrease the older adult's likelihood of developing a fever.

Correct answer: B

Rationale: Aging causes a decrease in vital capacity and decreased inspiratory reserve volume. As a result, the examiner may observe a shallower inspiratory phase and an increased respiratory rate in older adults. Contrary to common belief, the increased rigidity of arterial walls actually makes the pulse easier to palpate in aging adults. Pulse pressure is widened, not decreased, due to changes in systolic and diastolic blood pressures. Furthermore, changes in the body's temperature regulatory mechanism make older individuals less likely to develop a fever but more susceptible to hypothermia.

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