Nursing Elites

1. Which action by the novice nurse indicates a need for further teaching?

• A. The nurse fails to wear gloves when removing a dressing.
• B. The nurse applies an oxygen saturation monitor to the earlobe.
• C. The nurse elevates the head of the bed to check blood pressure.
• D. The nurse places the extremity in a dependent position to acquire a peripheral blood sample.

Correct answer: A

Rationale: The correct answer is A. The novice nurse failing to wear gloves when removing a dressing indicates a need for further teaching to emphasize infection control practices. This action can lead to the spread of infections. Choices B, C, and D are incorrect because they demonstrate proper nursing skills and techniques. Applying an oxygen saturation monitor to the earlobe, elevating the head of the bed to check blood pressure, and placing the extremity in a dependent position to acquire a peripheral blood sample all reflect understanding of correct procedures in patient care.

2. While assessing a client who is dying for signs of impending death, what should the nurse observe for?

• A. Elevated blood pressure
• B. Cheyne-Stokes respiration
• C. Elevated pulse rate
• D. Decreased temperature

Correct answer: B

Rationale: When assessing a client for signs of impending death, the nurse should observe for Cheyne-Stokes respiration. This pattern involves rhythmic waxing and waning of respirations from very deep breathing to very shallow breathing with periods of temporary apnea. It is often associated with cardiac failure and can be a significant indicator of impending death. Elevated blood pressure and pulse rate are not typical signs of impending death; in fact, they may indicate other conditions. A decreased temperature is also not a common sign of impending death, as temperature changes can vary among individuals and may not always correlate with the dying process.

3. In a brief treatment program, what is a realistic short-term goal for a client who was raped?

• A. Identify all psychosocial problems
• B. Eliminate the client's enticing behaviors
• C. Resolve feelings of trauma and fear
• D. Verbalize feelings about the event

Correct answer: D

Rationale: A realistic short-term goal for a client who was raped and is receiving a brief treatment program is for the client to verbalize feelings about the event. This goal focuses on helping the client express their emotions, which can be a crucial step in the healing process. Options A and C are incorrect because a brief treatment program is not typically aimed at identifying or resolving all psychosocial problems or deep-rooted trauma and fear. Option B is also incorrect as the goal is to support the client in processing their feelings rather than focusing on behaviors.

4. There are many types of torts that can be committed against clients. They include all of the following except:

• A. assault.
• B. battery.
• C. negligence.
• D. felony.

Correct answer: D

Rationale: The correct answer is 'felony.' Felonies are serious crimes punishable by time in prison and are not considered types of torts. Types of torts include assault, battery, negligence, as well as other examples like slander, invasion of privacy, false imprisonment, and fraud. Assault involves the threat of harm, battery involves physical harm, and negligence involves a failure to exercise reasonable care. These are all civil wrongs (torts) rather than criminal offenses (felonies), making 'felony' the correct choice.

5. In performing a psychosocial assessment, the nurse begins by asking questions that encourage the client to describe problematic behaviors and situations. The next step is to elicit the client's:

• A. feelings about what has been described
• B. thoughts about what has been described
• C. possible solutions to the problem
• D. intent in sharing the description

Correct answer: B

Rationale: In a psychosocial assessment, the nurse should progress from having the client describe problematic behaviors to eliciting their thoughts about the dilemmas. This step provides essential assessment data and insights into the client's interpretation of the situation. Asking about feelings, solutions, or intent in sharing the description is premature at this stage. Understanding the client's thoughts is crucial before delving into more complex emotional or problem-solving aspects. Therefore, the correct answer is to elicit the client's thoughts about the described behaviors and situations, as this helps the nurse gain a deeper understanding of the client's perspective and thought processes.

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