Nursing Elites

1. The nurse overhears two nursing students talking about a client in the cafeteria. What should the nurse do first?

• A. Report the incident to the nursing supervisor.
• B. Write up a variance report about the incident.
• C. Instruct the students that this is a violation of HIPAA.
• D. Notify the students' faculty regarding the violation.

Correct answer: C

Rationale: The correct answer is to instruct the students that discussing a client in a public area like the cafeteria violates HIPAA regulations. This is important to educate the students about patient confidentiality and the consequences of breaching it. Reporting to the nursing supervisor or faculty should come after addressing the students directly. Writing up a variance report is not the immediate action needed in this situation, as educating the students about their mistake should be the priority. It is essential to address the issue at the source by educating the students first rather than escalating the matter to supervisors or faculty immediately.

2. A homeless person has been admitted to the medical unit and placed on airborne precautions for suspected active TB infection. The nurse will assess for these signs and symptoms (Select one that doesn't apply).

• A. Weight gain
• B. Fatigue
• C. Bloody sputum
• D. Diaphoresis during sleep

Correct answer: A

Rationale: The correct answer is 'Weight gain.' When assessing for signs and symptoms of active TB infection, weight loss is typically observed rather than weight gain. Other common signs and symptoms include fatigue, bloody sputum, and diaphoresis during sleep. Fatigue, bloody sputum, and diaphoresis during sleep are all associated with active TB infection. Weight gain is not typically seen in active TB; instead, patients usually experience weight loss due to the impact of the infection on their overall health.

3. The LPN is preparing to ambulate a client post total knee replacement. Which of the following actions should the nurse perform prior to ambulating the client?

• A. Assist the client to a sitting position at the edge of the bed
• B. Have the client march in place for 30 seconds
• C. Have the client raise his arms above his head
• D. Ask the client the last time he fell

Correct answer: A

Rationale: The correct action to perform before ambulating a client post total knee replacement is to assist the client to a sitting position at the edge of the bed. This step is crucial to prevent orthostatic hypotension and ensure the client is ready to stand and walk safely. Having the client march in place or raise his arms above his head are not necessary preparations for ambulation. While knowing about the client's fall history is important for safety reasons, it is not the priority action immediately before ambulating the client.

4. Following a thyroidectomy, a client is complaining of shortness of breath (SOB) and neck pressure. Which nursing action is the best response?

• A. Stay with the client, remove the dressing, and elevate the head of bed.
• B. Call a code, open the trach set, and position the client supine.
• C. Have the client say "EEE"? to check for laryngeal integrity.
• D. Immediately go to the nurse's station and call the physician

Correct answer: A

Rationale: Correct! The client is displaying signs of respiratory distress after a thyroidectomy. By staying with the client, removing the dressing around the neck, and elevating the head of the bed, the nurse can assess the airway and breathing status more effectively. This immediate action can help alleviate any potential airway obstruction. Choice B is incorrect because calling a code and opening the trach set without initial assessment and basic interventions may delay necessary actions. Choice C is incorrect as having the client say "EEE"? is not as immediate or effective in addressing the respiratory distress. Choice D is incorrect as leaving the client alone and calling the physician without providing immediate assistance can be detrimental in a situation of potential airway compromise.

5. Which intervention should the nurse stop the nursing assistant from performing?

• A. Emptying the Jackson-Pratt drainage of the client post cholecystectomy
• B. Performing passive range of motion on the client with right-sided paralysis
• C. Placing the traction weights on the bed to transfer the client to X-ray
• D. Discarding the first urine voided by the client starting a 24-hour urine test

Correct answer: C

Rationale: Placing traction weights on the bed to transfer the client to X-ray is an intervention that the nurse should stop the nursing assistant from performing. Traction should never be relieved without a doctor's order as it can result in muscle spasm and tissue damage. The other choices are appropriate nursing interventions and should not be stopped. Emptying the Jackson-Pratt drainage, performing passive range of motion, and collecting the first urine void for a 24-hour urine test are all within the scope of practice and do not pose immediate risks to the client's well-being.

Similar Questions