Nursing Elites

1. Which behavior by a new nurse would indicate to the charge nurse that this nurse is following standard precautions?

• A. Wearing clean gloves while performing a heel stick on an infant
• B. Wearing the same gloves for assessments of clients in the same room
• C. Wearing sterile gloves when changing the urine bag and nasogastric canister of an infected client
• D. Donning a gown when responding to a request by the family to check the IV pump on a client with rotavirus

Correct answer: A

Rationale: The correct answer is wearing clean gloves while performing a heel stick on an infant. Standard precautions require the use of gloves when there is a risk of exposure to blood or body fluids. Clean gloves are suitable for this task as they provide adequate protection without being sterile. Choice B is incorrect because wearing the same gloves for different clients can lead to cross-contamination, violating standard precautions. Choice C is incorrect as sterile gloves are usually not required for changing a urine bag and nasogastric canister unless a specific aseptic technique is indicated; standard precautions do not demand sterile gloves for such tasks. Choice D is incorrect as donning a gown is not necessary for checking an IV pump unless there is a risk of exposure to bodily fluids that would necessitate full-body protection, which is not indicated in this scenario.

2. What is most important for the healthcare professional to do prior to initiating peritoneal dialysis?

• A. Aspirate to check placement
• B. Ensure the client voids
• C. Irrigate the catheter to maintain patency
• D. Warm the fluids

Correct answer: D

Rationale: The correct answer is to warm the fluids. Warming the dialysis fluids is crucial before initiating peritoneal dialysis to prevent abdominal discomfort and promote vasodilation, which helps in achieving good exchange in the peritoneum. Aspirating to check placement (Choice A) is not typically necessary before initiating peritoneal dialysis. Ensuring the client voids (Choice B) is not directly related to the procedure of peritoneal dialysis. Irrigating the catheter to maintain patency (Choice C) is usually done as part of routine care but is not specifically required prior to initiating peritoneal dialysis. Therefore, the most important action to take before starting peritoneal dialysis is to warm the fluids.

3. Which of the following injuries, presented by a client entering the Emergency Department, is the highest priority?

• A. open leg fracture
• B. open head injury
• C. stab wound to the chest
• D. traumatic amputation of a thumb

Correct answer: C

Rationale: A stab wound to the chest is the highest priority injury. This type of injury can lead to lung collapse and mediastinal shift, potentially resulting in death if left untreated. Treating an obstructed airway or a chest wound takes precedence over addressing hemorrhage. The principle of ABC (airway, breathing, and circulation) guides care decisions in prioritizing life-threatening situations. An open leg fracture, open head injury, and traumatic amputation of a thumb, while serious, do not pose an immediate threat to life compared to a stab wound to the chest. An open leg fracture may lead to significant blood loss but is not immediately life-threatening. An open head injury requires assessment and intervention but does not impact airway, breathing, or circulation directly. Traumatic amputation of a thumb is a serious injury but can be managed after addressing more life-threatening conditions.

4. A client has been diagnosed with Disseminated Intravascular Coagulation (DIC) and transferred to the medical intensive care unit (ICU) following an acute bleeding episode. In the ICU, continuous Heparin drip therapy is initiated. Which of the following assessment findings indicates a positive response to Heparin therapy?

• A. increased platelet count
• B. increased fibrinogen
• C. decreased fibrin split products
• D. decreased bleeding

Correct answer: B

Rationale: Effective Heparin therapy should halt the process of intravascular coagulation, leading to increased availability of fibrinogen. Heparin interferes with thrombin-induced conversion of fibrinogen to fibrin. Therefore, an increased fibrinogen level indicates a positive response to Heparin therapy. While increased platelet count and decreased bleeding are positive outcomes, the specific indicator for Heparin therapy response is the increase in fibrinogen level. Decreased fibrin split products would also be a positive response, but an increase in fibrinogen directly reflects the impact of Heparin therapy.

5. A client is experiencing chest pain. Which statement made by the client indicates angina rather than a myocardial infarction?

• A. "I became dizzy when I stood up."?
• B. "I was nauseated and began vomiting."?
• C. "The pain started in my chest and stopped after I sat down."?
• D. "The pain began with a migraine and progressed to numbness in my left arm."?

Correct answer: B

Rationale: The correct answer is: '"The pain started in my chest and stopped after I sat down."? This statement suggests angina rather than a myocardial infarction because angina is typically triggered by exertion or stress and relieved by rest. Nausea and vomiting (Choice B) are more commonly associated with a myocardial infarction. Choices A and D are not typical symptoms of either angina or myocardial infarction.

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