Nursing Elites

1. The nurse is caring for a patient in the hospital. The nurse observes the nursing assistive personnel (NAP) turning off the handle faucet with bare hands. Which professional practice principle supports the need for follow-up with the NAP?

• A. The nurse is responsible for providing a safe environment for the patient.
• B. This step is crucial in the process of handwashing.
• C. Different scopes of practice allow for procedure modifications.
• D. Leaving the water running wastes resources and money.

Correct answer: A

Rationale: The correct answer is A. The nurse is responsible for providing a safe environment for the patient. In this situation, the nurse should follow up with the nursing assistive personnel (NAP) who turned off the handle faucet with bare hands to ensure infection control practices are maintained. This action is crucial to prevent the spread of infections in the hospital setting. Choice B is incorrect because the question is not specifically about handwashing procedures but about infection control practices. Choice C is incorrect as it does not address the potential risk of infection transmission. Choice D is incorrect as it is unrelated to the main concern of infection control in this scenario.

2. A nurse is preparing a client for surgery. The client refuses to remove a religious medal. What is the nurse's best response?

• A. Ask the family to remove the medal
• B. Place the medal in a safe place for the client
• C. Allow the client to keep the medal during surgery
• D. Inform the client that the medal must be removed

Correct answer: C

Rationale: The correct answer is to allow the client to keep the medal during surgery. Clients may retain religious medals or jewelry during surgery if it does not interfere with the procedure. Asking the family to remove the medal (Choice A) may not be respecting the client's wishes. Placing the medal in a safe place for the client (Choice B) may cause distress to the client who wants to keep it. Informing the client that the medal must be removed (Choice D) disregards the client's beliefs and preferences.

3. A nurse is caring for a patient with heart failure who has developed pulmonary edema. What is the nurse's priority action?

• A. Administer a diuretic as prescribed.
• B. Place the patient in a high Fowler's position.
• C. Administer oxygen via nasal cannula.
• D. Monitor the patient's lung sounds every 2 hours.

Correct answer: B

Rationale: The correct answer is to place the patient in a high Fowler's position. This position helps improve lung expansion and oxygenation in cases of pulmonary edema by reducing venous return to the heart and enhancing respiratory mechanics. Administering a diuretic (Choice A) can be important but is not the priority over positioning in this situation. Administering oxygen (Choice C) is essential, but the priority action for improving oxygenation is the positioning of the patient. Monitoring lung sounds (Choice D) is crucial for ongoing assessment but is not the priority action when the patient is in distress with pulmonary edema.

4. A nurse is caring for a client who has an indwelling urinary catheter and a prescription for a urine specimen for culture and sensitivity. Which of the following actions should the nurse take?

• A. Wipe the area around the needleless port with sterile water
• B. Insert the syringe into the needleless port at a 60-degree angle
• C. Withdraw 3 to 5 ml of urine from the port
• D. Don sterile gloves

Correct answer: C

Rationale: The correct action for the nurse to take is to withdraw 3 to 5 ml of urine from the port for an accurate culture and sensitivity test. Wiping the area around the needleless port with sterile water (Choice A) is not necessary when obtaining a urine specimen. Inserting the syringe into the needleless port at a 60-degree angle (Choice B) is incorrect as it does not align with the correct procedure for obtaining a urine specimen. Donning sterile gloves (Choice D) is a good practice but not the immediate action required for obtaining a urine specimen.

5. A nurse is assessing a client who has asthma. Which of the following areas should the nurse evaluate as the most reliable indicator of central cyanosis?

• A. Oral mucosa
• B. Conjunctivae
• C. Soles of the feet
• D. Ear lobes

Correct answer: A

Rationale: Central cyanosis is best assessed by examining the oral mucosa, as it is a more reliable indicator compared to other areas like the conjunctivae, soles of the feet, and ear lobes. The oral mucosa reflects the oxygen saturation levels of the blood more accurately. Conjunctivae and ear lobes may show cyanosis, but they are not as reliable as the oral mucosa. The soles of the feet are not typically used to assess central cyanosis.

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