Nursing Elites

1. Which of the following statements from a client may indicate that they are at a higher risk for a fall?

• A. "I would like to get out of bed but would like to put on my non-skid socks first."?
• B. "Can you make sure the two bedrails are raised before leaving the room?"?
• C. "I think I'm ready to walk a longer distance with the cane today."?
• D. "I need to get out of bed to go to the bathroom now. I cannot find my glasses but cannot wait."?

Correct answer: D

Rationale: The correct answer is 'I need to get out of bed to go to the bathroom now. I cannot find my glasses but cannot wait.' This statement indicates that the client is in a hurry and unable to find their glasses, which could increase the risk of a fall due to impaired vision. Choice A about putting on non-skid socks shows the client's awareness of fall prevention, reducing the risk. Choice B demonstrates the client's request for bedrails to be raised, which is a safety measure, reducing the risk as well. Choice C suggests the client's readiness to walk a longer distance with a cane, indicating progress in mobility but not necessarily a higher fall risk.

2. Which of the following statements by a client indicates adequate understanding of preparation for a lipoprotein fractionation test?

• A. "I cannot eat or drink after midnight."?
• B. "I cannot eat for 12 hours before the test."?
• C. "I need to limit my fluid intake."?
• D. "I need to ingest a lipid solution."?

Correct answer: B

Rationale: The correct statement regarding preparation for a lipoprotein fractionation test is that the client cannot eat for 12 hours before the test. It is important to note that the client can drink an unrestricted amount of water. Limiting fluid intake is not necessary for this test. There is no need for the client to ingest a lipid solution as part of the preparation. Therefore, the other choices are incorrect.

3. During the change of shift, the oncoming nurse notes a discrepancy in the number of Percocet (Oxycodone) listed and the number present in the narcotic drawer. The nurse's first action should be to:

• A. Notify the hospital pharmacist
• B. Notify the nursing supervisor
• C. Notify the Board of Nursing
• D. Notify the director of nursing

Correct answer: B

Rationale: The first action the nurse should take is to report the finding to the nursing supervisor and follow the chain of command. Notifying the nursing supervisor allows for immediate action within the facility to address the discrepancy. If it is found that the pharmacy is in error, then notifying the hospital pharmacist (Choice A) would be appropriate. Choices C and D, notifying the Board of Nursing and the director of nursing, are not the initial steps to take. These options may be necessary if theft is suspected or if the facility's internal response is inadequate. Therefore, they are incorrect answers.

4. When a client needs oxygen therapy, what is the highest flow rate that oxygen can be delivered via nasal cannula?

• A. 2 liters/minute
• B. 4 liters/minute
• C. 6 liters/minute
• D. 8 liters/minute

Correct answer: C

Rationale: The correct answer is 6 liters/minute. When a client requires oxygen therapy, the maximum flow rate that oxygen can be delivered via nasal cannula is 6 liters/minute. Nasal cannula can effectively deliver oxygen up to 6 liters/minute. Flow rates exceeding 6 liters/minute may lead to drying of the nasal passages and discomfort for the client. Higher flow rates, like 8 liters/minute, should be administered using a mask to ensure sufficient oxygenation. Options A, B, and D are incorrect as they indicate flow rates that surpass the recommended maximum for nasal cannula delivery.

5. While undergoing fetal heart monitoring, a pregnant Native-American woman requests that a medicine woman be present in the examination room. Which of the following is an appropriate response by the nurse?

• A. "I will assist you in arranging to have a medicine woman present."?
• B. "We do not allow medicine women in exam rooms."?
• C. "That does not make any difference in the outcome."?
• D. "It is old-fashioned to believe in that."?

Correct answer: A

Rationale: The correct response is to show cultural awareness and respect the client's request by offering assistance in arranging for the medicine woman to be present. This approach acknowledges the importance of cultural beliefs and practices in the client's care, fostering trust and cooperation. Choices B, C, and D are inappropriate as they dismiss or belittle the client's cultural beliefs, showing insensitivity and lack of respect, which can negatively impact the nurse-client relationship.

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