Nursing Elites

1. While repositioning a comatose client, the nurse senses a tingling sensation as she lowers the bed. What action should she take?

• A. Unplug the bed's power source.
• B. Remove the client from the bed immediately.
• C. Notify the biomedical department at once.
• D. Turn off the oxygen.

Correct answer: A

Rationale: The correct action for the nurse to take when sensing a tingling sensation while lowering the bed with a comatose client is to unplug the bed's power source. This should be the initial step as there may be a fault in the bed's grounding. Removing the client from the bed immediately is not safe until the electrical issue is resolved. Notifying the biomedical department is important but should come after ensuring the immediate safety of the client. Turning off the oxygen is not necessary unless there is a specific issue related to oxygen delivery, which is not indicated in this scenario.

2. The nurse assesses a client for physiological risk factors for falls. The nurse should conclude that the client is not at risk if which of the following is discovered?

• A. history of dizziness
• B. need for a wheelchair due to reduced mobility
• C. weakness and fatigue noted when climbing stairs
• D. intact recent and remote memory

Correct answer: D

Rationale: The correct answer is intact recent and remote memory. Intact memory function indicates that the client is less likely to be at risk for falls as it suggests cognitive awareness and orientation, which are important for safety. Choices A, B, and C are risk factors for falls: a history of dizziness can lead to imbalance, the need for a wheelchair due to reduced mobility can increase fall risk, and weakness and fatigue when climbing stairs indicate physical limitations that predispose a client to falls. Therefore, these options would suggest an increased risk for falls.

3. What action should the emergency triage nurse take upon receiving the history that a client has a severe cough, fever, night sweats, and body wasting?

• A. Place the client in isolation until further assessment is completed.
• B. Seclude the client from other clients and visitors.
• C. Perform no intervention until test results confirm a diagnosis.
• D. Don personal protective equipment immediately.

Correct answer: B

Rationale: The correct action for the emergency triage nurse to take upon receiving the history that a client has a severe cough, fever, night sweats, and body wasting is to seclude the client from other clients and visitors. These symptoms are suggestive of tuberculosis, a highly infectious disease. By secluding the client, the nurse can prevent the potential spread of the infection to others. Donning personal protective equipment, including gown, gloves, and a mask, is crucial when providing care to the client, but the immediate priority is to prevent the spread of infection by isolating the client. Placing the client in isolation until further assessment is completed ensures that the client is kept away from others until a proper diagnosis and treatment plan can be established, reducing the risk of transmission. Performing no intervention until test results confirm a diagnosis is inappropriate as immediate isolation is necessary in suspected cases of highly infectious diseases like tuberculosis.

4. Under what circumstances is the legal right to confidentiality of client information waived?

• A. When a court system subpoenas information.
• B. When a family member requests health care information of a client.
• C. When a living will takes effect.
• D. When the client is declared incompetent by the legal system.

Correct answer: A

Rationale: The legal right to confidentiality of client information is waived when a court system subpoenas information. This occurs when information is required for legal proceedings to occur, such as through summonses, court orders, or litigation information necessary for the court. Subpoenas are legal orders that compel the disclosure of information. The other choices do not inherently waive the legal right to confidentiality. A family member's request for health care information would typically require the client's consent or fall under specific legal exceptions. A living will dictates end-of-life care preferences but does not necessarily waive confidentiality. Lastly, the declaration of incompetence may impact decision-making capacity but does not automatically waive confidentiality.

5. After receiving a recent tattoo, someone should be screened for:

• A. tuberculosis.
• B. herpes.
• C. hepatitis.
• D. syphilis.

Correct answer: C

Rationale: After receiving a recent tattoo, screening for hepatitis is crucial due to the risk of blood-borne hepatitis B or C if strict sterile procedures are not followed during the tattooing process. Tuberculosis is an airborne pathogen and is not directly related to receiving a tattoo. Herpes and syphilis are infections spread through direct contact, such as sexual contact, and are not typically associated with tattooing.

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