Nursing Elites

1. What is the primary route of transmission of MRSA?

• A. Shared needles
• B. Hands of healthcare workers
• C. Items in the healthcare environment
• D. Blood transfusions

Correct answer: B

Rationale: The correct answer is 'Hands of healthcare workers.' MRSA is primarily transmitted via the unwashed hands of healthcare workers who can carry the Staphylococcus aureus bacterium from one patient to another. Shared needles, items in the healthcare environment, and blood transfusions are not the main routes of transmission for MRSA. Shared needles can transmit bloodborne pathogens, items in the healthcare environment can harbor bacteria but are not the primary mode for MRSA, and blood transfusions are not a common route for MRSA transmission.

2. A client is being assisted with ambulation in the hallway using a gait belt when they become dizzy and start to faint. What is the first action the nurse should take?

• A. Stand behind the client and prepare to catch them if they fall
• B. Assist the client to sit in the nearest chair or slide down along a wall
• C. Grasp the client under the arms and pull them upward
• D. Call for help from nearby staff

Correct answer: A

Rationale: If a client becomes dizzy and starts to faint while being assisted with ambulation, the nurse's first action should be to assist the client into a sitting position to prevent or reduce the impact of a fall. This can be done by guiding the client to sit in the nearest chair or sliding down along a wall for support. Option A is incorrect because standing behind the client may not prevent a fall and could potentially lead to injury. Option C is incorrect as pulling the client upward may worsen the situation. Option D, calling for help, is not the first action to take when the client is at risk of falling.

3. 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.

4. A patient's nursing diagnosis is Insomnia. The desired outcome is: 'Patient will sleep for a minimum of 5 hours nightly by October 31.' On November 1, a review of the sleep data shows the patient sleeps an average of 4 hours nightly and takes a 2-hour afternoon nap. Which evaluation should be documented?

• A. Consistently demonstrated
• B. Often demonstrated
• C. Sometimes demonstrated
• D. Never demonstrated

Correct answer: D

Rationale: The correct answer is 'Never demonstrated.' Despite the patient sleeping a total of 6 hours daily, it is not achieved in one uninterrupted session at night as per the desired outcome. The patient's habit of taking a 2-hour afternoon nap also affects the evaluation. Therefore, the outcome should be evaluated as 'Never demonstrated.' Choice A, 'Consistently demonstrated,' is incorrect because the desired outcome of sleeping for a minimum of 5 hours nightly in one session is not met. Choice B, 'Often demonstrated,' is incorrect as the patient's sleep pattern does not consistently align with the desired outcome. Choice C, 'Sometimes demonstrated,' is also incorrect as the patient's sleep pattern does not meet the specific criteria set in the desired outcome.

5. Your patient who had AIDS/HIV has just died. Should you still use standard precautions as you provide post-mortem care?

• A. Yes, because the virus is still transmissible
• B. Yes, because respect must still be maintained
• C. No, because the virus is no longer transmissible
• D. No, because it is disrespectful

Correct answer: A

Rationale: Yes, you should still use standard precautions even after an HIV/AIDS patient has died. The virus can remain infectious after death, and healthcare workers need to protect themselves from potential exposure. Choice B is incorrect because while respect is important, the primary reason for using standard precautions is to prevent transmission of infectious diseases. Choice C is incorrect as the virus can still be transmissible even after the patient's death. Choice D is incorrect as using standard precautions is a matter of infection control, not a question of respect.

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