Nursing Elites

1. A client on the nursing unit is terminally ill but remains alert and oriented. Three days after admission, the nurse observes signs of depression. The client states, 'I'm tired of being sick. I wish I could end it all.' What is the most accurate and informative way to record this data in a nursing progress note?

• A. Client appears to be depressed, possibly suicidal
• B. Client reports being tired of being ill and wants to die
• C. Client does not want to live any longer and is tired of being ill
• D. Client states, 'I'm tired of being sick. I wish I could end it all.'

Correct answer: D

Rationale: Subjective data includes thoughts, beliefs, feelings, perceptions, and sensations that are apparent only to the person affected and cannot be measured, seen, or felt by the nurse. This information should be documented using the client's exact words in quotes. The other options indicate that the nurse has drawn the conclusion that the client no longer wishes to live. From the data provided, the cues do not support this assumption. A more complete assessment should be conducted to determine if the client is suicidal.

2. Improper placement of the hands under the rib cage when performing the Heimlich maneuver could result in:

• A. damage to the manubrium of the sternum.
• B. damage to the xiphoid process.
• C. damage to the coccyx.
• D. None of the above is possible, even with improper hand placement.

Correct answer: B

Rationale: The xiphoid process is a small, cartilaginous extension at the inferior end of the sternum. Placing the hands improperly during the Heimlich maneuver too close to this process can result in it breaking off and potentially causing damage to internal organs. Choices A and C are incorrect because the manubrium of the sternum and the coccyx are not in the area where the hands would typically be placed during the Heimlich maneuver.

3. For a patient who is blood type AB, which blood product can they receive?

• A. Plasma from a type B donor
• B. Whole blood from a type A donor
• C. Packed RBCs from a type O donor
• D. All of the above

Correct answer: C

Rationale: A patient with blood type AB has AB antigens on their red blood cells. This means they can only receive blood products that are compatible with these antigens. Choice A is incorrect because an AB patient cannot receive plasma from a type B donor due to the antibodies present in type B plasma. Choice B is incorrect because an AB patient cannot receive whole blood from a type A donor as it contains incompatible antigens. Choice C is the correct answer because an AB patient can receive packed RBCs from a type O donor. Type O donors have no A or B antigens, making their blood compatible for transfusion to recipients with any blood type. Therefore, choices A and B are incorrect, and the correct choice is C.

4. A nurse is completing an incident report about a medication error that she made when she accidentally administered too much insulin to a diabetic client. All of the following are components of this documentation EXCEPT:

• A. The reason for administering the wrong dose
• B. The type of drug involved
• C. The amount of insulin that was given
• D. Any adverse effects on the client

Correct answer: A

Rationale: When completing an incident report for a medication error, it is essential to include factual information such as the type of drug involved, the amount administered, and any adverse effects on the client. However, stating the reason for administering the wrong dose should be avoided in documentation. The focus should be on reporting what happened rather than assigning blame or admitting fault. This approach helps in ensuring a thorough and accurate account of the medication error without introducing subjective elements that could complicate the investigation or resolution process. Therefore, the correct answer is 'The reason for administering the wrong dose.' Choices A, B, and D are vital components of incident report documentation, providing crucial details that help in understanding the error and its impact on the client.

5. An adult's blood pressure reads 40/20. You place the patient in a Trendelenberg position before rechecking the blood pressure. What actions will you take to position the patient correctly?

• A. lower the head of the bed and raise the foot of the bed
• B. raise the head of the bed up to about 60 to 75 degrees
• C. raise the head of the bed up to about 75 to 90 degrees
• D. raise the siderails and place the bed in the high position

Correct answer: A

Rationale: In a Trendelenberg position, used for low blood pressure, the correct action is to lower the head of the bed and raise the foot of the bed. This positioning facilitates the return of blood to the heart and helps increase blood pressure. Option B, raising the head of the bed to 60 to 75 degrees, is incorrect as it is not the Trendelenberg position. Option C, raising the head of the bed to 75 to 90 degrees, is incorrect as it does not align with the Trendelenberg position. Option D, raising the siderails and placing the bed in the high position, is incorrect as it does not address the specific positioning required for the Trendelenberg position.

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