Nursing Elites

1. A nurse enters a client's room and finds them on the floor. The client's roommate reports that the client was trying to get out of bed and fell over the side rail onto the floor. Which of the following statements should the nurse document about this incident?

• A. Incident report completed.
• B. Client climbed over the side rails.
• C. Client was trying to get out of bed.
• D. Client found lying on floor.

Correct answer: C

Rationale: The correct answer is C: "Client was trying to get out of bed." This statement accurately reflects the sequence of events leading to the client's fall and provides crucial information for assessing the situation. Choice A is incorrect because documenting the completion of an incident report is not relevant to describing the incident itself. Choice B incorrectly states that the client climbed over the side rails, which is not supported by the information provided. Choice D is too vague and does not provide details about the client's actions prior to falling.

2. A nurse is caring for a client who has a nasogastric (NG) tube and is receiving intermittent feedings through an open system. Which of the following actions should the nurse take first?

• A. Make sure the enteral formula is at room temperature.
• B. Wipe the top of the formula can with alcohol.
• C. Rinse the feeding bag with water between feedings.
• D. Tell the client to keep the head of the bed elevated at least 30�

Correct answer: B

Rationale:

3. A nurse manager has two out of six staff nurses call in sick for one shift. Because of reduced availability of staff, the manager decides to manage the unit with the three remaining nurses, which keeps the unit at minimal staffing standards. What type of decision-making strategy would this be?

• A. Satisficing
• B. Routine
• C. Adaptive
• D. Rationalizing

Correct answer: A

Rationale: Satisficing is the correct decision-making strategy in this scenario. The nurse manager is not aiming for the best solution but rather choosing an alternative that is good enough given the circumstances of staff shortage. Choice B, Routine, does not apply here as the situation is not part of the manager's regular tasks. Choice C, Adaptive, involves adjusting to new conditions, which is not the primary focus in this scenario. Choice D, Rationalizing, does not fit as the decision made is more about finding an acceptable solution rather than justifying it.

4. Which information is most important for the nurse to report to the health care provider before a patient with type 2 diabetes is prepared for a coronary angiogram?

• A. The patient�s most recent HbA1C was 6.5%
• B. The patient�s admission blood glucose is 128 mg/dL.
• C. The patient took the prescribed metformin (Glucophage) today
• D. The patient took the prescribed captopril (Capoten) this morning.

Correct answer: C

Rationale:

5. Which of the following laws govern nursing practice?

• A. Statutory laws
• B. Common law
• C. Administrative laws
• D. Constitutional laws

Correct answer: A

Rationale: Statutory laws are laws created by legislative bodies, such as state legislatures. In the context of nursing practice, statutory laws govern areas like licensure requirements, scope of practice, and professional standards. Common law, choice B, is based on court decisions and precedents, not specifically related to nursing practice. Administrative laws, choice C, deal with regulations set by administrative agencies rather than governing nursing practice directly. Constitutional laws, choice D, pertain to the fundamental principles outlined in a country's constitution and are not specific to regulating nursing practice.

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