Nursing Elites

1. A male patient who had surgery 2 days ago for head and neck cancer is about to make his first attempt to ambulate outside his room. The nurse notes that he is steady on his feet and that his vision was unaffected by the surgery. Which of the following nursing interventions would be appropriate?

• A. Encourage the patient to walk in the hall alone
• B. Discourage the patient from walking in the hall for a few more days
• C. Accompany the patient for his walk
• D. Consult a physical therapist before allowing the patient to ambulate

Correct answer: C

Rationale: Accompanying the patient for his walk is the appropriate nursing intervention in this scenario to ensure his safety during his first ambulation. This allows the nurse to provide immediate assistance if needed and ensures the patient's well-being during this critical postoperative period.

2. A client is recovering from an acute myocardial infarction that occurred 3 days ago. Which of the following instructions should the nurse include in the care plan?

• A. Perform an ECG every 12 hours.
• B. Place the client in a supine position while resting.
• C. Draw a troponin level every 4 hours.
• D. Obtain a cardiac rehabilitation consultation.

Correct answer: D

Rationale: After an acute myocardial infarction, cardiac rehabilitation is crucial for the client's recovery. It helps improve the client's overall cardiovascular health, reduces the risk of future cardiac events, and promotes a healthy lifestyle. The other options do not directly address the importance of cardiac rehabilitation in the client's recovery process.

3. When preparing an in-service on malpractice issues in nursing, which of the following examples should the nurse include in the teaching?

• A. Leaving a nasogastric tube clamped after administering oral medication
• B. Documenting communication with a provider in the progress notes of the client's medical record
• C. Administering potassium via IV bolus
• D. Placing a yellow bracelet on a client who is at risk for falls

Correct answer: C

Rationale: Administering potassium via IV bolus is a high-risk procedure that requires careful attention and adherence to established protocols to prevent serious complications like cardiac arrest. Errors in administering IV medications, especially potent ones like potassium, can lead to severe harm to the patient and potential legal consequences for the healthcare provider. Therefore, including this example in the in-service on malpractice issues helps emphasize the importance of safe medication administration practices and the potential implications of errors.

4. Which of the following parameters should be checked when assessing respirations?

• A. Rate
• B. Rhythm
• C. Symmetry
• D. All of the above

Correct answer: D

Rationale: When assessing respirations, it is essential to evaluate the rate at which breaths are taken, the rhythm of breathing patterns, and the symmetry of chest expansion. Each of these parameters provides valuable information about a person's respiratory status. Therefore, it is important to assess all of the listed parameters to have a comprehensive understanding of the individual's respiratory function.

5. A client is scheduled for a thoracentesis. Which of the following supplies should NOT be in the client's room?

• A. Oxygen equipment
• B. Incentive spirometer
• C. Pulse oximeter
• D. Sterile dressing

Correct answer: B

Rationale: During a thoracentesis procedure, the focus is on draining fluid or air from the pleural space. An incentive spirometer, which helps improve lung function, is not a necessary supply for this specific procedure. Oxygen equipment, pulse oximeter for monitoring oxygen saturation levels, and sterile dressing for wound care may be needed during or after the procedure.

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