Nursing Elites

1. While receiving an infusion of cefazolin sodium, the client complained of itchy skin. The nurse observed warm, flushed skin with a red rash on the arms, chest, and back. The health care provider was promptly notified.

• A. The client is apparently allergic to cefazolin sodium, as indicated by warm, flushed skin and a rash on the arms, chest, and back.
• B. The client had an allergy to cefazolin sodium.
• C. The health care provider was notified because a rash developed while the client was receiving cefazolin sodium.
• D. During an infusion of cefazolin sodium, the client complained that his skin was itchy. The client's skin was warm and flushed, with a red rash on the arms, chest, and back. The health care provider was notified.

Correct answer: D

Rationale: Accurate and objective documentation is essential during an incident report. Choice A makes an assumption of allergy based on subjective interpretation, which is not appropriate. Choice B states a conclusion without proper documentation. Choice C is incomplete as it fails to provide a detailed account of the observed symptoms. Choice D offers a precise description of the client's symptoms, actions taken, and notification of the healthcare provider, making it the most suitable documentation choice.

2. Which of the following is not considered one of the five rights of medication administration?

• A. client
• B. drug
• C. dose
• D. routine

Correct answer: D

Rationale: The five rights of medication administration are dose, client, drug, route, and time. The correct answer is 'routine' as it is not commonly recognized as one of the essential rights in medication administration. Choice A, client, is necessary to ensure the right medication is administered to the right individual. Choice B, drug, is crucial to confirm the correct medication is given. Choice C, dose, is essential to ensure the right amount of medication is administered. Choice D, routine, is not typically included in the five rights of medication administration and is therefore the correct answer.

3. Which of the following indicates a hazard for a client on oxygen therapy?

• A. A 'No Smoking' sign is on the door.
• B. The client is wearing a synthetic gown.
• C. Electrical equipment is grounded.
• D. Matches are removed.

Correct answer: B

Rationale: The correct answer is that the client is wearing a synthetic gown. A synthetic gown might generate sparks of static electricity, which can be a fire hazard, especially in the presence of oxygen. Clients on oxygen therapy should wear cotton gowns to minimize the risk of fire. The other options are not hazards for a client on oxygen therapy: having a 'No Smoking' sign on the door promotes safety by preventing smoking, ensuring electrical equipment is grounded reduces the risk of electrical hazards, and removing matches decreases the risk of fire hazards.

4. What is the most appropriate feeding method for a client who is unable to swallow?

• A. Nothing by mouth
• B. Nasogastric feedings
• C. Clear liquids
• D. Total parenteral nutrition

Correct answer: B

Rationale: Nasogastric feedings are the most appropriate feeding method for a client who is unable to swallow. Providing nothing by mouth can lead to nutritional deficiencies, while clear liquids might cause aspiration. Total parenteral nutrition is not necessary if the gastrointestinal tract is functional. Nasogastric feedings are preferred as they can safely provide nutrition without the risks associated with not eating or aspirating.

5. After securing the client's safety from a faulty electric bed, what should the nurse do next?

• A. Discuss the matter with the client's significant others.
• B. Document the incident in the client's record in detail.
• C. Notify the physician.
• D. Prepare an incident report.

Correct answer: D

Rationale: After ensuring the client's safety from the faulty electric bed, the nurse should prioritize preparing an incident report. This report documents the details of what happened and is crucial for quality improvement and risk management. Choice A, discussing the matter with the client's significant others, may be important in some cases but is not the immediate priority after a safety incident. Choice B, documenting the incident in the client's record, is necessary but should be preceded by preparing an incident report. Choice C, notifying the physician, is important but not as urgent as preparing the incident report to ensure timely reporting and investigation of the safety issue.

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