Nursing Elites

1. The UAP reports to the PN that an assigned client experiences SOB when the bed is lowered for bathing. Which action should the PN implement?

• A. Obtain further data about the client's activity intolerance to position changes
• B. Advise the UAP to allow the client to rest before completing the bath
• C. Direct the UAP to obtain vital signs and a pulse oximetry reading
• D. Notify the healthcare provider about the client's episode of SOB

Correct answer: B

Rationale: Advising the UAP to allow the client to rest before completing the bath is the most appropriate action to take. This helps manage the shortness of breath (SOB) experienced by the client and prevents further stress. By giving the client time to rest, the PN ensures the client's comfort and safety during care activities. The other options are not the most immediate or appropriate actions in this scenario: obtaining further data about activity intolerance (choice A) may delay addressing the current issue, obtaining vital signs and pulse oximetry (choice C) is important but not as immediate as allowing the client to rest, and notifying the healthcare provider (choice D) is premature before trying a simple intervention like allowing the client to rest.

2. An 8-year-old child is placed in 90-90 traction for a fractured femur. The nurse notices that the weights are touching the foot of the bed. What action should the nurse take?

• A. No bowel movement for two days
• B. Mother helps reposition the child
• C. Ensure weights are not touching the foot of the bed
• D. Child wiggles toes freely when tickled

Correct answer: C

Rationale: The nurse should ensure that the weights in traction are not touching the foot of the bed. This is crucial to maintain proper alignment and effectiveness of the traction. When the weights touch the bed, it can compromise the traction's function and delay healing. Choices A, B, and D are incorrect as they do not address the issue of ensuring that the weights are not touching the bed, which is essential for the traction to work effectively.

3. A nurse who receives a patient in the operative suite prior to the actual surgery is in charge of the patient’s care. Which of the following is NOT a task related to the nurse’s intraoperative care?

• A. Go over the surgical procedure with the patient before he or she is anesthetized
• B. Strictly adhere to asepsis during all intraoperative procedures
• C. Provide emotional support to the patient and their family
• D. Monitor the patient’s physical status

Correct answer: A

Rationale: The correct answer is A. Going over the surgical procedure with the patient is typically done preoperatively, not intraoperatively. Intraoperative tasks of a nurse involve strictly adhering to asepsis during procedures, monitoring the patient's physical status, and providing emotional support to the patient and their family during the surgery. Choices B, C, and D are all tasks that are directly related to the nurse's responsibilities during the intraoperative phase of care.

4. A client is post-operative day two from a total hip arthroplasty. The nurse notices the surgical wound is red and warm to the touch. What is the most appropriate action?

• A. Apply an ice pack to the incision site.
• B. Monitor the client's temperature.
• C. Document the findings and continue to monitor.
• D. Notify the healthcare provider.

Correct answer: D

Rationale: The correct action when a nurse notices redness and warmth at the surgical wound post total hip arthroplasty is to notify the healthcare provider. These signs may indicate an infection, and prompt evaluation by the healthcare provider is crucial to initiate appropriate treatment. Applying an ice pack (Choice A) may not address the underlying issue of a potential infection. Monitoring the client's temperature (Choice B) is important but not the priority when signs of infection are present. Documenting the findings and continuing to monitor (Choice C) is necessary but should be accompanied by notifying the healthcare provider for further assessment and intervention.

5. A Native American client is admitted with a diagnosis of psychosis not otherwise specified. The client's family seems to regard the client's hallucinations as normal. What assessment can be made?

• A. The client's family regards the hallucinations from a cultural context
• B. The client will benefit from a talking circle
• C. The client will need a medicine man
• D. The client will need a single room

Correct answer: A

Rationale: Choice A is correct because the family may interpret the client's hallucinations through their cultural lens, potentially viewing them as normal or spiritually significant. Understanding and acknowledging the cultural context is essential for providing culturally sensitive care. Choices B, C, and D are incorrect because while talking circles and seeking guidance from a medicine man may be culturally relevant interventions in some contexts, the priority in this situation is to recognize and respect the family's perspective on the client's hallucinations.

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