Nursing Elites

1. Which behavior is most likely to result in a breach of client confidentiality?

• A. Discussing a client’s condition during a teaching conference for nursing staff caring for the client
• B. Two nurses planning a client’s care while having lunch in the hospital cafeteria
• C. Nursing students on the same team discussing their assigned client’s conditions
• D. A registered nurse privately sharing personal feelings about a client with another nurse on the team

Correct answer: B

Rationale: The correct answer is B. Discussing client information in a public area, such as a cafeteria, may lead to breaches of confidentiality. Choice A involves discussing a client's condition in a professional setting, which is not likely to result in a breach as it is for educational purposes. Choice C involves nursing students discussing their assigned client's conditions, which is common in a learning environment and not necessarily a breach of confidentiality. Choice D involves a private conversation between healthcare professionals, which is less likely to result in a breach compared to discussing in a public area like a cafeteria where non-authorized individuals may overhear the conversation.

2. A mother brings her child, who has a history of asthma, to the emergency room. The child is wheezing and speaking one word between each breath. The child is anxious, tachycardic, and has labored respirations. Which assessment is most important for the nurse to obtain?

• A. Type of inhaler the child typically uses on a regular basis
• B. Frequency of rescue inhaler use during the week
• C. Last dose and type of rescue inhaler used by the child
• D. Type of allergen exposure or trigger for the current episode

Correct answer: C

Rationale: The correct answer is C because knowing the last dose and type of rescue inhaler used helps assess if the child has received adequate treatment and if further intervention is needed. This information is crucial in managing an acute asthma exacerbation. Choice A, the type of inhaler the child typically uses, is less critical during an emergency. Choice B, the frequency of rescue inhaler use during the week, is important for general asthma management but does not provide immediate guidance in the acute situation. Choice D, the type of allergen exposure or trigger, is more relevant for preventive strategies and does not directly impact the immediate treatment of the child's acute asthma attack.

3. The healthcare provider prescribes lidocaine (Lidoject-1) 100 mg IV push for ventricular tachycardia for an unconscious client. What is the nurse's priority intervention?

• A. Measure the client's cardiac output
• B. Assess neurological status q15 min
• C. Collect a blood specimen for serum potassium
• D. Infuse lidocaine (Lidoject-1) at 20 to 50 mg/min

Correct answer: B

Rationale: The priority intervention for the nurse is to assess the client's neurological status q15 min. This is crucial to monitor for potential side effects of lidocaine, especially its neurotoxic effects. While measuring the client's cardiac output and collecting a blood specimen for serum potassium are important assessments, assessing the neurological status is the priority when administering lidocaine. Infusing lidocaine at a specific rate should follow the initial assessment of the client's neurological status to ensure safety.

4. The school nurse is screening students for spinal abnormalities and instructs each student to stand up and then touch their toes. Which finding indicates that a student should be referred for scoliosis evaluation?

• A. Inability to touch their toes
• B. Asymmetry of the shoulders when standing upright
• C. Audible crepitus when bending
• D. An exaggerated upper thoracic convex curvature

Correct answer: B

Rationale: Asymmetry of the shoulders when standing upright is a common indicator of scoliosis. This finding suggests a possible spinal abnormality and should prompt further evaluation. Choices A, C, and D are not specific indicators of scoliosis. Inability to touch their toes may indicate flexibility issues or tightness in the hamstrings. Audible crepitus when bending may suggest joint degeneration or inflammation. An exaggerated upper thoracic convex curvature could indicate poor posture or other spinal abnormalities but is not directly indicative of scoliosis.

5. The nurse is calculating the one-minute Apgar score for a newborn male infant and determines that his heart rate is 150 beats/minute, he has a vigorous cry, his muscle tone is good with total flexion, he has quick reflex irritability, and his color is dusky and cyanotic. What Apgar score should the nurse assign to the infant?

• A. 8
• B. 9
• C. 6
• D. 7

Correct answer: A

Rationale: The correct answer is A: 8. The Apgar score is calculated based on five parameters: heart rate, respiratory effort, muscle tone, reflex irritability, and color. In this case, the infant has a good heart rate, vigorous cry, good muscle tone, and quick reflex irritability, which would total to 8. The only factor affecting the score is the cyanotic color, which could indicate potential respiratory or circulatory issues. Choices B, C, and D are incorrect as they do not reflect the overall assessment provided in the scenario.

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