Nursing Elites

1. A new staff nurse completes orientation to the psychiatric unit. This nurse will expect to ask an advanced practice nurse to perform which action for patients?

• A. Perform mental health assessment interviews
• B. Establish therapeutic relationships
• C. Prescribe psychotropic medications
• D. Individualize nursing care plans

Correct answer: C

Rationale: Prescriptive privileges are granted to Master's-prepared nurse practitioners who have taken special courses on prescribing medications. The nurse prepared at the basic level performs mental health assessments, establishes relationships, and provides individualized care planning. In this scenario, the new staff nurse would ask the advanced practice nurse to prescribe psychotropic medications, as this is within their scope of practice and expertise. Establishing therapeutic relationships, performing mental health assessments, and individualizing care plans are typically responsibilities of staff nurses at the basic level, not advanced practice nurses.

2. The supervising RN asks you to bring the unit's collected lab specimens to the lab 'stat'. You should ______________.

• A. not decline this task because nurses do not handle 'stats'.
• B. run this errand as promptly as possible
• C. run this errand immediately and without delay
• D. Complete this task before the end of your shift or after your lunch.

Correct answer: C

Rationale: In healthcare settings, 'stat' is commonly used to indicate that something should be done immediately and without any delay. It is a critical term used to prioritize urgent tasks. Nurses are responsible for various tasks, including handling urgent requests such as transporting lab specimens promptly. Option A is incorrect as nurses can handle urgent tasks like 'stats'. Option B is not as specific as option C, which clearly emphasizes the need for immediate action. Option D is incorrect as it suggests delaying the task until later, which goes against the urgency implied by the term 'stat'.

3. A client is preparing to administer an enema to a 64-year-old client. Which of the following actions of the nurse is most appropriate?

• A. Assist the client to lie in the semi-Fowler position
• B. Apply lubricating jelly to the tip of the catheter before insertion
• C. Instill a total of 30cc of fluid into the client's rectum
• D. Ask the client to hold the solution in for 30 seconds

Correct answer: B

Rationale: When administering an enema to a client, the nurse should place the client in the Sims' position for easy access. The correct action is to apply lubricating jelly to the tip of the catheter before insertion to facilitate a smoother procedure. It is essential to instill a maximum of 750 to 1000 cc of fluid for an adult client, not just 30cc. Following administration, the nurse should ask the client to hold the solution for at least 5 minutes to allow for the desired effect of the enema. Therefore, choice B is the most appropriate action, as choices A, C, and D are incorrect due to inaccuracies in positioning, enema volume, and retention time.

4. The client starting an exercise program will progress to walking a 20-minute mile in one month.

• A. Client will walk quickly three times a day
• B. Client will be able to walk a mile
• C. Client will have no alteration in breathing during the walk
• D. Client will progress to walking a 20-minute mile in one month

Correct answer: D

Rationale: Outcome statements must be written in behavioral terms and identify specific, measurable client behaviors. They are stated in terms of the client with an action verb that, under identified conditions, will achieve the desired behavior. Choice A lacks specificity and does not mention a target time or goal. Choice B is vague and does not provide a specific target for improvement. Choice C focuses on a negative outcome (no alteration) rather than a positive goal. The correct answer, Choice D, is specific, measurable, and time-bound, making it a suitable outcome statement for a client starting an exercise program.

5. An 86-year-old client with decreased visual acuity who uses a cane for mobility requires fall prevention education. What should the nurse teach this client to reduce the risk of falling at home?

• A. Take off shoes while in the house and wear only socks
• B. Limit activities to the lower level of the home
• C. Keep a lamp near the door of every room
• D. Install non-slip pads in the shower or bathtub

Correct answer: D

Rationale: To reduce the risk of falling at home for an elderly client with decreased visual acuity and using a cane for mobility, installing non-slip pads in the shower or bathtub is crucial. This measure helps prevent slips and falls in areas where water accumulation may occur. While taking off shoes and wearing socks may seem comfortable, it increases the risk of slipping. Limiting activities to the lower level of the home may restrict the client's independence and quality of life unnecessarily. Keeping a lamp near the door of every room may improve visibility but does not directly address the risk of falls associated with mobility and visual acuity issues.

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