Nursing Elites

1. A nurse is observing a newly licensed nurse providing care for a client who reports pain. The nurse checked the client’s MAR and noted the last dose of pain medication was administered 6 hours ago. The prescription specifies administration every 4 hours PRN for pain. The nurse administered the medication and followed up with the client 40 minutes later, who reported improvement. What did the newly licensed nurse overlook in the nursing process?

• A. Assessment
• B. Planning
• C. Intervention
• D. Evaluation

Correct answer: A

Rationale: The correct answer is 'Assessment.' In the nursing process, assessment is the first step, crucial before any intervention. Assessment involves gathering data about the client's condition to establish a baseline for evaluating responses to interventions. In this scenario, the newly licensed nurse missed assessing the client's pain intensity, location, quality, and other relevant factors before administering the pain medication. While the follow-up evaluation with the client is commendable, it cannot replace the initial assessment. Planning involves setting goals and outcomes, intervention is the action taken to achieve these goals, and evaluation assesses the client's response to the intervention.

2. When teaching adult cardiopulmonary resuscitation (CPR) to a group of newly licensed nurses, what should the charge nurse instruct as the initial response in CPR?

• A. Confirm unresponsiveness
• B. Check for a pulse
• C. Begin chest compressions
• D. Call for emergency help

Correct answer: A

Rationale: The correct initial response in CPR is to confirm unresponsiveness. This step is crucial to ensure that the person actually needs CPR before proceeding with further actions. Checking for unresponsiveness is essential to determine if the individual is in need of immediate assistance. Checking for a pulse or beginning chest compressions without confirming unresponsiveness could waste valuable time and potentially harm the individual. Calling for emergency help is important, but it should follow the confirmation of unresponsiveness to ensure timely activation of emergency services.

3. An adult client is found to be unresponsive during morning rounds. After checking for responsiveness and calling for help, what should the nurse do next?

• A. Check the carotid pulse
• B. Deliver 5 abdominal thrusts
• C. Give 2 rescue breaths
• D. Open the client's airway

Correct answer: D

Rationale: After confirming unresponsiveness and calling for help, the next step in basic life support is to open the client's airway. This ensures that the airway is clear and allows for effective ventilation. Checking the carotid pulse is not necessary at this stage as airway management takes precedence. Delivering abdominal thrusts is not indicated for an unresponsive client as it is for conscious choking individuals. Giving rescue breaths should only be done after ensuring the airway is open to allow for effective ventilation.

4. A male client being discharged with a prescription for the bronchodilator theophylline tells the nurse that he understands he is to take three doses of the medication each day. Since timed-release capsules are not available at the time of discharge, which dosing schedule should the LPN advise the client to follow?

• A. 9 a.m., 1 p.m., and 5 p.m.
• B. 8 a.m., 4 p.m., and midnight.
• C. Before breakfast, before lunch, and before dinner.
• D. With breakfast, with lunch, and with dinner.

Correct answer: B

Rationale: The correct dosing schedule for the client to follow is to take the medication at 8 a.m., 4 p.m., and midnight. This timing spaces the doses evenly over the waking hours, ensuring consistent therapeutic levels of the medication. Choice A (9 a.m., 1 p.m., and 5 p.m.) does not evenly distribute the doses throughout the day. Choices C (Before breakfast, before lunch, and before dinner) and D (With breakfast, with lunch, and with dinner) do not provide the required frequency of dosing needed for optimal therapeutic effect.

5. When transferring a client to a long-term care facility, what information should the nurse include in the handoff report?

• A. Frequency of previous vital sign measurements
• B. Number of family members who have visited
• C. Time of the client's last bath
• D. Effectiveness of the last dose of pain medication

Correct answer: D

Rationale: The correct answer is D: 'Effectiveness of the last dose of pain medication.' When transferring a client to a long-term care facility, it is crucial to provide information on the effectiveness of the last dose of pain medication to ensure continuity of care and appropriate pain management. This information helps the receiving facility understand the client's current pain status and plan future interventions accordingly. Choices A, B, and C are less relevant for the handoff report in this scenario. The frequency of previous vital sign measurements may be important, but the immediate effectiveness of pain medication takes precedence. The number of family members who have visited and the time of the client's last bath are not as critical for the receiving facility's immediate care planning compared to pain management details.

Similar Questions