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. Why should direct care providers avoid glued-on artificial nails?

• A. Interfere with dexterity of the fingers.
• B. Could fall off in a patient's bed.
• C. Harbor microorganisms.
• D. Can scratch a patient.

Correct answer: C

Rationale: Direct care providers, including nurses, should avoid glued-on artificial nails because studies have shown that artificial nails, especially when cracked, broken, or split, create crevices where microorganisms can thrive and multiply. This can lead to an increased risk of transmitting infections to patients. Therefore, the primary reason for avoiding glued-on artificial nails is their potential to harbor harmful microorganisms, making option C the correct choice. Options A, B, and D are incorrect because while they may present some issues, the primary concern is the risk of microbial contamination associated with artificial nails.

3. Before allowing the client's infant granddaughter to visit before the client's scheduled heart transplant, the nurse decides it would be beneficial to collaborate with which of the following? Select all that apply.

• A. Client and Family
• B. Other nursing staff on the unit
• C. Security department
• D. Hospital administration

Correct answer: B

Rationale: Collaborating with the client and family is crucial as it fosters a sense of autonomy and active involvement in the healthcare process for the client. Involving other nursing staff ensures the successful implementation of the planned intervention and provides support for the client's needs. Collaboration with the security department or hospital administration is not necessary in this situation, as the focus should be on the client's well-being and family involvement during a sensitive time.

4. The healthcare provider is examining a patient who is reporting "feeling cold."? Which is a mechanism of heat loss in the body?

• A. Exercise
• B. Radiation
• C. Metabolism
• D. Food digestion

Correct answer: B

Rationale: When the body needs to lose heat, one of the mechanisms it employs is radiation. Radiation involves the transfer of heat from the body to the environment in the form of infrared waves. While metabolism, exercise, and food digestion contribute to heat production, they are not mechanisms for heat loss. Metabolism generates heat as a byproduct, exercise increases metabolic rate leading to heat production, and food digestion involves some heat generation, but these processes do not directly facilitate heat loss. Therefore, in the scenario where the patient is feeling cold, radiation is the primary mechanism for the body to lose excess heat and maintain a stable internal temperature.

5. The nurse is taking an initial blood pressure reading on a 72-year-old patient with documented hypertension. How should the nurse proceed?

• A. Cuff should be placed on the patient's arm and inflated 30 mm Hg above the point at which the palpated pulse disappears.
• B. Cuff should be inflated to 200 mm Hg in an attempt to obtain the most accurate systolic reading.
• C. Cuff should be inflated 30 mm Hg above the patient's pulse rate.
• D. After confirming the patient's previous blood pressure readings, the cuff should be inflated 30 mm Hg above the highest systolic reading recorded.

Correct answer: C

Rationale: When measuring blood pressure, it's important to account for the possibility of an auscultatory gap, which occurs in about 5% of individuals, particularly those with hypertension due to a noncompliant arterial system. To detect an auscultatory gap, the cuff should be inflated 20 to 30 mm Hg beyond the point at which the palpated pulse disappears. This ensures an accurate measurement of blood pressure by overcoming the potential gap in sounds. Choice A is correct as it follows this guideline. Choices B and C are incorrect because inflating the cuff to 200 mm Hg or above the patient's pulse rate does not address the specific issue of an auscultatory gap. Choice D is incorrect as it focuses on the patient's previous readings rather than the current measurement technique needed to detect an auscultatory gap.

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