Nursing Elites

1. Which statement best describes evidence-based practice?

• A. Reading and analyzing research reports to determine their implementation in nursing practice
• B. Collecting data to evaluate the efficiency of nursing practice in delivering quality care
• C. Monitoring unit practices to ensure adherence to Joint Commission standards
• D. Using the most effective, current, and applicable information to guide nursing care for the best outcomes

Correct answer: D

Rationale: Evidence-based practice involves utilizing the most effective, current, and relevant information to inform nursing care decisions for optimal client outcomes. While research reports and data collection are important components of evidence-based practice, the essence lies in integrating all available information to determine the best course of action. Monitoring compliance with standards, as described in choices A and C, is essential for quality assurance but does not capture the comprehensive nature of evidence-based practice.

2. In which of the following ways can a nurse promote sleep for a client experiencing insomnia?

• A. Assist the client in using the bathroom one hour after going to bed
• B. Give the client a massage before bedtime
• C. Tuck bed sheets and blankets tightly around the client once settled in bed
• D. Give the client a pair of socks to wear if their feet become cold

Correct answer: D

Rationale: A nurse can promote sleep for a client experiencing insomnia by addressing factors that may hinder sleep. Cold feet can disrupt sleep, so providing the client with socks to keep their feet warm can enhance comfort and aid in promoting sleep. The correct answer focuses on a direct intervention to address a specific issue that can impact sleep quality. Choices A, B, and C do not directly address the issue of cold feet, which is a common problem that can interfere with sleep in individuals with insomnia. Assisting the client to use the bathroom, giving a massage in the morning, or tucking in bed sheets tightly do not target the discomfort caused by cold feet, making them less effective interventions for promoting sleep in this scenario.

3. When should you wear gloves?

• A. preparing infant formula for a newborn baby
• B. transferring breast milk into a baby bottle
• C. knocking on a patient's door
• D. opening a patient's door

Correct answer: B

Rationale: You must wear gloves when transferring breast milk into a baby bottle because breast milk is considered a bodily fluid. It is essential to avoid direct contact to prevent contamination. When preparing infant formula, gloves are not required as formula is not a bodily fluid. Knocking on or opening a patient's door does not involve direct contact with bodily fluids, so gloves are unnecessary in those situations.

4. A client has died approximately one hour ago. The nurse notes that the client's temperature has decreased in the last hour since their death. Which of the following processes explains this phenomenon?

• A. Rigor mortis
• B. Postmortem decomposition
• C. Algor mortis
• D. Livor mortis

Correct answer: C

Rationale: Algor mortis occurs after death when the body's circulation stops, and the client's temperature begins to fall. The client's temperature will drop by approximately 1.8 degrees per hour until it reaches room temperature. During algor mortis, the client's skin gradually loses its elasticity. Rigor mortis refers to the stiffening of the body after death due to chemical changes in the muscles. Postmortem decomposition is the breakdown of tissues after death. Livor mortis is the pooling of blood in the dependent parts of the body, causing a purple-red discoloration.

5. Which of these actions illustrates the correct technique for a nurse when assessing oral temperature with a glass thermometer?

• A. Wait 30 minutes if the patient has ingested hot or iced liquids.
• B. Leave the thermometer in place for 3 to 4 minutes if the patient is afebrile.
• C. Shake the glass thermometer down to 35.5�C before taking the patient's temperature.
• D. Place the thermometer at the base of the tongue and ask the patient to close his or her lips.

Correct answer: B

Rationale: The correct technique for assessing oral temperature with a glass thermometer involves leaving the thermometer in place for 3 to 4 minutes if the patient is afebrile and up to 8 minutes if the patient is febrile. Waiting 30 minutes if the patient has ingested hot or iced liquids is incorrect; instead, the nurse should wait 15 minutes in such cases. Shaking the glass thermometer down to 35.5�C, not 37.5�C, is the correct procedure before taking the patient's temperature. Placing the thermometer at the base of the tongue, not the front, and asking the patient to close their lips is the proper way to position the thermometer. Therefore, the correct answer is to leave the thermometer in place for 3 to 4 minutes if the patient is afebrile and up to 8 minutes if the patient is febrile.

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