Nursing Elites

1. When planning a cultural assessment, what component should the nurse include?

• A. Family history
• B. Chief complaint
• C. Medical history
• D. Health practices

Correct answer: D

Rationale: When conducting a cultural assessment, it is essential to include the patient's health practices. Health practices encompass the beliefs, values, and behaviors related to health and illness within a specific cultural context. These practices provide insight into how individuals perceive and manage their health. Family history, chief complaint, and medical history are crucial components of a patient's overall assessment but do not directly relate to a cultural assessment. Focusing on health practices allows the nurse to better understand the patient's cultural background and tailor care to meet their specific needs.

2. An 86-year-old client with decreased visual acuity who uses a cane for mobility requires fall prevention education. What should the nurse teach this client to reduce the risk of falling at home?

• A. Take off shoes while in the house and wear only socks
• B. Limit activities to the lower level of the home
• C. Keep a lamp near the door of every room
• D. Install non-slip pads in the shower or bathtub

Correct answer: D

Rationale: To reduce the risk of falling at home for an elderly client with decreased visual acuity and using a cane for mobility, installing non-slip pads in the shower or bathtub is crucial. This measure helps prevent slips and falls in areas where water accumulation may occur. While taking off shoes and wearing socks may seem comfortable, it increases the risk of slipping. Limiting activities to the lower level of the home may restrict the client's independence and quality of life unnecessarily. Keeping a lamp near the door of every room may improve visibility but does not directly address the risk of falls associated with mobility and visual acuity issues.

3. The nurse is assessing children in a pediatric clinic. Which statement is true regarding the measurement of blood pressure in children?

• A. Blood pressure guidelines for children are based on age.
• B. Phase II Korotkoff sounds are the best indicator of systolic blood pressure in children.
• C. Using a Doppler device is recommended for accurate blood pressure measurements until adolescence.
• D. The disappearance of phase V Korotkoff sounds can be used for the diastolic reading in children.

Correct answer: D

Rationale: The disappearance of phase V Korotkoff sounds can be used for the diastolic reading in children, as well as in adults. Blood pressure guidelines for children are based on more than just age, but also sex and height. Phase I Korotkoff, not Phase II, is the best indicator of systolic blood pressure. The true statement regarding the measurement of blood pressure in children is that the disappearance of phase V Korotkoff sounds can be used for the diastolic reading in children, as well as in adults.

4. Surgical asepsis is being performed when:

• A. wiping down exam tables with bleach
• B. sterilizing instruments
• C. changing table paper
• D. wearing gloves when performing injections

Correct answer: B

Rationale: Surgical asepsis refers to the process of maintaining a sterile environment to prevent the introduction of pathogens to a patient's body. Sterilizing instruments is a crucial aspect of surgical asepsis as it ensures that the instruments used during procedures are free from microorganisms that could cause infections. Wiping down exam tables with bleach may help in cleaning and disinfecting surfaces but does not pertain directly to maintaining a sterile field. Changing table paper is important for cleanliness and infection control but is not specifically related to surgical asepsis. Wearing gloves when performing injections is important for standard precautions and preventing the spread of infection but does not encompass the concept of surgical asepsis, which focuses on maintaining a sterile field during invasive procedures.

5. You are working the 8 am to 4 pm shift. You begin to vomit at 3 pm and you do not think that you are able to continue working. You decide to immediately go home without notifying your RN supervisor. You have ________________.

• A. enough sick time, so this is not a problem.
• B. finished all your work, so this is not a problem.
• C. seriously abandoned the patients.
• D. seriously abused and neglected the patients.

Correct answer: D

Rationale: Patient abandonment is a serious violation that can lead to disciplinary action and immediate termination of employment. It is defined as leaving patients without proper consent from the supervisor. In this scenario, leaving work without notifying the RN supervisor and potentially leaving patients unattended is considered patient abandonment, as it compromises patient safety and care. Choices A and B are incorrect because having sick time or finishing work does not justify leaving without proper protocol. Choice D is incorrect as the scenario does not indicate abuse or neglect towards the patients.

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