Nursing Elites

1. You see a patient lying on the floor of the bathroom. You are NOT assigned to this patient. What is the first thing that you should do?

• A. Get the nurse who is caring for the patient.
• B. Tell the nurse that the patient has had another seizure.
• C. Observe the patient for any injuries and call out for help.
• D. Nothing. This patient is not one of your assignments.

Correct answer: C

Rationale: The correct course of action in this situation is to observe the patient for any injuries and call out for help. It is crucial to act immediately in an emergency, regardless of whether the patient is under your care. Checking for injuries and seeking assistance can help ensure the patient receives prompt and appropriate care. Choosing to inform the nurse of a seizure without evidence or taking no action because the patient is not your assignment are not optimal responses. In a healthcare setting, patient safety and well-being should always be the top priority.

2. What is the anatomic structure located in the middle of the heart that separates the right and left ventricles?

• A. Septum
• B. Sputum
• C. Separator
• D. None of the above

Correct answer: A

Rationale: The correct answer is the septum. The septum is a structure located in the middle of the heart that separates the right and left ventricles. It plays a crucial role in maintaining the separation between the two ventricles to ensure efficient blood flow. The other choices, 'Sputum' and 'Separator,' are incorrect as they do not refer to the anatomic structure in the heart that serves this specific function. 'Sputum' is a term used to describe phlegm or mucus, not an anatomical structure, and 'Separator' is a generic term that does not specifically identify the cardiac structure mentioned in the question.

3. Which of the following is recommended by Joint Commission guidelines regarding the use of restraints?

• A. Vest restraints should be used because they are the least restrictive type.
• B. Restraints should be used for 48 hours in non-psychiatric patients.
• C. Restraints should be applied to prevent wandering behavior.
• D. Alternative measures must be attempted first.

Correct answer: D

Rationale: When considering the use of restraints, Joint Commission guidelines emphasize the importance of attempting alternative measures before resorting to restraint application. This ensures that a comprehensive assessment is conducted and less restrictive interventions are explored. Using restraints solely based on their perceived level of restrictiveness, as stated in choice A, is not in line with the recommended approach. Restraints should not be used to manage wandering behavior, as indicated in choice C. Additionally, the statement in choice B regarding the duration of restraint use is inaccurate, as restraints on non-psychiatric patients should not exceed 24 hours according to The Joint Commission.

4. Which body plane divides the body into right and left sides?

• A. Frontal Plane
• B. Medial Plane
• C. Median Plane
• D. Transverse Plane

Correct answer: C

Rationale: The correct answer is the Median Plane, also known as the sagittal plane. It divides the body into right and left sides. The Frontal Plane, or coronal plane, divides the body into front and back sections. The Transverse Plane divides the body into superior (upper) and inferior (lower) sections. Therefore, choices A, B, and D are incorrect as they do not specifically divide the body into right and left sides.

5. A client is complaining of pain in his right hand after surgery. The IV in his hand has slowed down, and the skin around the site is reddened and cool. The client reports localized pain in the hand and fingers. What is the most likely cause of this client's pain?

• A. The client's IV is infiltrated
• B. The client is experiencing phlebitis from the last drug administered
• C. The client has a blood clot developing in the distal arteries of the wrist
• D. The client's pain is associated with myocardial ischemia and he is having a heart attack

Correct answer: A

Rationale: Pain, cool skin, and edema at an IV injection site indicate IV infiltration. The reddened and cool skin around the IV site, along with localized pain and a slowed IV drip rate, are classic signs of infiltration. Infiltration occurs when IV fluids or medications enter the surrounding tissues instead of the vein, leading to potential tissue damage. Phlebitis is inflammation of a vein, not infiltration. A blood clot in the distal arteries of the wrist would not cause these specific symptoms. Myocardial ischemia and heart attack are unrelated to the client's localized hand pain and IV issues.

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