Nursing Elites

1. You are ready to wash your patient's face. You would start by washing what area of the face?

• A. The forehead
• B. The eyes
• C. The ears
• D. The cheeks

Correct answer: B

Rationale: When washing a patient's face, it is essential to start by cleaning the eyes. The eye area is considered the priority because moving from an area that can potentially be infected to areas of the face and body that are least able to become infected with a washcloth helps prevent the spread of germs. Washing the forehead, ears, or cheeks before the eyes may risk transferring bacteria to a more sensitive area like the eyes, which could lead to infections or other complications. Therefore, starting with the eyes ensures proper hygiene and reduces the risk of introducing harmful microorganisms to the patient's face.

2. When preparing a patient on complete bed rest to eat, at what degree angle or more should you put the head of the bed up?

• A. 10
• B. 15
• C. 20
• D. 30

Correct answer: D

Rationale: The correct answer is D: 30. When a patient is on complete bed rest, it is essential to elevate the head of the bed at a 30-degree angle or more before meals. This position helps prevent choking and aspiration of food during eating by promoting proper swallowing and digestion. Choices A, B, and C are incorrect because they do not provide the optimal elevation needed to support safe and effective feeding for a patient on complete bed rest.

3. Which desired outcome written by the nurse is correctly written and measurable?

• A. Client will have a normal bowel pattern by April 2
• B. The client will lose 4 lbs. within the next 2 weeks
• C. The nurse will provide skin care at least 3 times each day
• D. The client will breathe better after resting for 10 minutes

Correct answer: B

Rationale: An outcome statement must describe the observable client behavior that should occur in response to the nursing interventions. It consists of a subject, action verb, conditions under which the behavior is to be performed, and the level at which the client will perform the desired behavior. Option B is correctly written and measurable as it includes all the required elements: subject (client), action verb (lose), conditions (within the next 2 weeks), and the level at which the behavior should occur (4 lbs.). Option A lacks the conditions and a specific level, making it not measurable. Option C is a nursing intervention rather than a client goal. Option D does not provide a specific level at which the client should perform the desired behavior, making it not measurable as well.

4. One of your patients is dependent on a mechanical ventilator for their respiratory needs. The patient cannot breathe on their own. Suddenly, the lights in the patient's room and the entire nursing unit go off. You realize that the electric power has been lost. What is the first thing that you should do for this patient?

• A. Plug the ventilator into the red outlet in the room.
• B. Plug the ventilator into the blue outlet in the room.
• C. Use an Ambu bag to ventilate the patient.
• D. Call the doctor about this emergency.

Correct answer: B

Rationale: In healthcare facilities, emergency generators are in place in case of power outages. The red outlets in patient rooms are connected to the emergency generator and provide power during such situations. By plugging the ventilator into the red outlet, you ensure that the patient's mechanical ventilation needs are met despite the power loss. Using an Ambu bag or calling the doctor should be secondary actions after ensuring the ventilator is powered correctly. Plugging the ventilator into the blue outlet is incorrect and can result in the ventilator not functioning during a power outage.

5. A client has just started a transfusion of packed red blood cells that a physician ordered. Which of the following signs may indicate a transfusion reaction?

• A. The client suddenly complains of back pain and has chills
• B. The client develops dependent edema in the extremities
• C. The client has a seizure
• D. The client's heart rate drops to 60 bpm

Correct answer: A

Rationale: The correct answer is when the client suddenly complains of back pain and has chills. Signs of a transfusion reaction include back pain, chills, dizziness, increased temperature, and blood in the urine. These signs indicate a possible adverse reaction to the blood transfusion. Dependent edema in the extremities is not typically associated with a transfusion reaction. A seizure is not a common sign of a transfusion reaction unless it is due to severe complications. A decrease in heart rate to 60 bpm is not a typical sign of a transfusion reaction, but rather bradycardia may indicate other underlying conditions or medications.

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