Nursing Elites

1. A charge nurse discovers that a nurse did not notify the provider that a client's condition had changed. The charge nurse should identify that the nurse is accountable for which of the following torts?

• A. Negligence
• B. Assault
• C. Battery
• D. Defamation

Correct answer: A

Rationale: The correct answer is A: Negligence. Negligence in nursing occurs when a healthcare provider fails to take appropriate action that a reasonably prudent provider would take in a similar situation, such as not notifying the provider of changes in a client's condition. In this scenario, the nurse's failure to inform the provider of the client's changed condition constitutes negligence. Choices B, C, and D are incorrect. Assault involves the intentional threat of bodily harm to another person, battery is the intentional harmful or offensive touching of another person without their consent, and defamation is the act of making false statements about someone to a third party that harms that person's reputation.

2. A nurse is preparing to administer enteral feedings to a client with an NG tube. Which action should the nurse take first?

• A. Flush the tube with 100 mL of water
• B. Verify tube placement
• C. Elevate the head of the bed
• D. Measure the residual gastric volume

Correct answer: B

Rationale: Verifying tube placement is the priority action the nurse should take before administering enteral feedings. This step ensures that the NG tube is correctly positioned, reducing the risk of complications such as aspiration pneumonia. Flushing the tube with water, elevating the head of the bed, and measuring residual gastric volume are important steps in enteral feeding administration but come after verifying tube placement. Flushing the tube with water helps clear the tubing, elevating the head of the bed reduces the risk of aspiration, and measuring residual gastric volume helps assess the client's tolerance to feedings.

3. A nurse is assessing a client who reports a burning sensation at the site of a peripheral IV. The site is red and swollen. What is the nurse's priority action?

• A. Apply a cold compress
• B. Discontinue the IV line
• C. Elevate the limb
• D. Increase the IV flow rate

Correct answer: B

Rationale: The correct answer is to discontinue the IV line. The client's symptoms of a burning sensation, redness, and swelling at the IV site indicate phlebitis, which is inflammation of the vein. The priority action in this situation is to remove the source of irritation, which is the IV line, to prevent further complications such as infection or thrombosis. Applying a cold compress may provide temporary relief but does not address the underlying issue. Elevating the limb is not the priority in this case. Increasing the IV flow rate can worsen the phlebitis by causing further irritation to the vein.

4. A nurse is reviewing the health history of a client who has a hip fracture. What risk factor should the nurse identify for developing pressure injuries?

• A. Frequent repositioning
• B. Poor nutrition
• C. Increased fluid intake
• D. Use of a special mattress

Correct answer: B

Rationale: Corrected Rationale: Poor nutrition increases the risk of developing pressure injuries as it impairs skin integrity and healing. Frequent repositioning, increased fluid intake, and the use of a special mattress are all important interventions for preventing pressure injuries, rather than risk factors for developing them. Repositioning helps relieve pressure, adequate fluid intake maintains skin hydration, and special mattresses redistribute pressure to prevent injuries.

5. A client who has recently developed fever, confusion, and a decreased level of consciousness is being admitted by a nurse. What should the nurse do first after obtaining the client's history and assessment?

• A. Administer prescribed antibiotics
• B. Initiate seizure precautions
• C. Identify the client's needs
• D. Place the client in isolation

Correct answer: C

Rationale: The correct answer is to identify the client's needs first. This allows the nurse to prioritize interventions based on the assessment findings. Administering prescribed antibiotics (choice A) should be based on a medical prescription and the identified infection. Initiating seizure precautions (choice B) is important but not the immediate priority in this case. Placing the client in isolation (choice D) is premature as the nurse needs to first assess and address the client's condition.

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