Nursing Elites

1. Which of the following activities would the nurse perform during the diagnosing phase of the nursing process? Select all that apply.

• A. Collect and organize client information
• B. Analyze data
• C. Identify problems, risks, and client strengths
• D. Develop nursing diagnoses

Correct answer: B

Rationale: During the diagnosing phase of the nursing process, the nurse analyzes the collected data to identify problems, risks, and client strengths, which then leads to developing nursing diagnoses. Collecting and organizing client information is part of the assessment phase, where data is gathered. Developing nursing diagnoses comes after data analysis in the diagnosing phase. Goal setting is a component of the planning phase, which follows the diagnosing phase.

2. Which is the most effective action for controlling the spread of infection?

• A. Thorough hand hygiene
• B. Wearing gloves and masks when providing direct client care
• C. Implementing appropriate isolation precautions
• D. Administering broad-spectrum prophylactic antibiotics

Correct answer: A

Rationale: Thorough hand hygiene is the most effective action for controlling the spread of infection as hands are a common source of transmission. Regular and routine hand hygiene helps prevent the movement of potentially infective materials. Wearing gloves and masks is important when providing direct client care to protect both the caregiver and the patient, but it is not as effective as thorough hand hygiene in preventing overall infection spread. Implementing appropriate isolation precautions is necessary for clients with known communicable diseases, but it is not as universally effective in preventing the spread of various infections. Administering broad-spectrum prophylactic antibiotics is not an appropriate measure for controlling the spread of infection as routine use can lead to superinfection and the development of resistant organisms.

3. When assessing a pulse, what should be noted?

• A. Rate
• B. Rate and quality
• C. Rate, quality, and fullness
• D. Rate, quality, fullness, and regularity

Correct answer: C

Rationale: When assessing a pulse, it is important to note the rate (number of beats per minute), quality (regular or irregular), and fullness (thread and weak or full and bounding). These aspects provide crucial information about the patient's cardiovascular status. Regularity, as mentioned in option D, is not typically assessed during a pulse check and is not necessary for routine pulse assessment. Choice A is too limited as it overlooks important aspects beyond just the rate. Choice B improves by adding quality but still lacks the fullness aspect. Choice C is the most comprehensive and accurate as it includes all three essential aspects for a thorough pulse assessment.

4. The nurse is reviewing percussion techniques with a new graduate nurse. Which action performed by the graduate nurse while percussing requires the nurse to intervene?

• A. Percussing twice over each area
• B. Striking with the fingertip, not the finger pad
• C. Using the wrist to make the strikes, not the arm
• D. Quickly lifting the striking finger after each stroke

Correct answer: A

Rationale: The correct answer is to percuss twice over each area, not once. This technique helps ensure a more accurate assessment. Striking with the fingertip instead of the finger pad is correct because the tip of the finger produces clearer sounds. Using the wrist to make the strikes instead of the arm is appropriate as it allows for more controlled and precise percussion. Quickly lifting the striking finger after each stroke is also correct to prevent damping off vibrations. Therefore, percussing once over each area (Choice A) is incorrect as it does not follow the standard percussion technique.

5. When dismissing a 5-year-old boy from the pediatrics unit, what type of seat belt restraint should the child wear as the parents drive the car to the front door of the hospital?

• A. A 5-point restraint in the back seat, facing backward
• B. A booster seat with a lap and shoulder belt in the back seat
• C. A lap belt in the back seat
• D. A lap and shoulder belt in the front seat

Correct answer: B

Rationale: A 5-year-old child riding in a car should use a restraint system for safety. The Centers for Disease Control and Prevention recommend that children under 13 years should not ride in the front seat of a car due to safety concerns. For a 5-year-old child, a booster seat with a lap and shoulder belt in the back seat is the most appropriate choice. This setup ensures proper protection and restraint for the child's size and age. Choice A is incorrect because a 5-point restraint system facing backward is not suitable for a 5-year-old child in a car. Choice C is incorrect as a lap belt alone does not provide adequate protection for a child of this age. Choice D is incorrect as children should not be seated in the front seat, especially at this young age.

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