Nursing Elites

1. A nurse has administered medications to a group of clients. For which of the following client situations should the nurse complete an incident report?

• A. Administering acetaminophen to an NPO client
• B. Administering insulin lispro to an NPO client
• C. Administering medication to the incorrect client
• D. Administering anticoagulants without checking INR

Correct answer: B

Rationale: The correct answer is B because administering insulin lispro to an NPO client can lead to hypoglycemia due to the lack of food to balance the medication. This situation poses a serious risk to the client's safety and should be documented in an incident report. Choice A is not as critical as insulin administration for an NPO client. Choice C is also serious but does not pose an immediate risk to the client's health. Choice D, administering anticoagulants without checking the INR, is important but does not require an incident report unless adverse effects occur, as it may not immediately endanger the client's life.

2. A client with a tracheostomy is experiencing increased secretions and labored breathing. What should the nurse do first?

• A. Administer a bronchodilator
• B. Suction the tracheostomy
• C. Encourage the client to cough
• D. Notify the provider

Correct answer: B

Rationale: The correct answer is to suction the tracheostomy first. When a client with a tracheostomy is experiencing increased secretions and labored breathing, suctioning the tracheostomy is the priority intervention to clear the airway and improve breathing. Administering a bronchodilator (Choice A) may help with breathing but should come after ensuring the airway is clear. Encouraging the client to cough (Choice C) may not be effective in clearing secretions from the tracheostomy. Notifying the provider (Choice D) can be done after ensuring immediate airway clearance.

3. What are the key components of a respiratory assessment?

• A. Inspection, Palpation, Percussion, Auscultation
• B. Inspection, Observation, Auscultation, Percussion
• C. Auscultation, Palpation, Observation, Percussion
• D. Observation, Palpation, Percussion, Auscultation

Correct answer: A

Rationale: The correct answer is A: Inspection, Palpation, Percussion, Auscultation. A focused respiratory assessment involves inspecting the chest for symmetry and signs of distress, palpating for tenderness or abnormal masses, performing percussion to assess underlying tissues, and auscultating lung sounds. Choice B is incorrect as observation is a broad term that can encompass both inspection and palpation. Choice C is incorrect as auscultation is usually performed after inspection and palpation. Choice D is incorrect as observation should be more specific, and auscultation is a key component that is typically done last in a respiratory assessment.

4. A client with acute diverticulitis is receiving teaching from a nurse. Which of the following statements by the client indicates an understanding of the instructions?

• A. I will avoid eating fiber until this condition resolves
• B. I will take a laxative daily
• C. I will receive the nutrients I need through my IV fluids
• D. I will eat only solid foods

Correct answer: A

Rationale: The correct answer is A. During acute diverticulitis, avoiding fiber is essential as it helps reduce irritation of the intestines. Choice B is incorrect because taking a laxative daily can exacerbate diverticulitis. Choice C is incorrect as IV fluids mainly provide hydration and electrolytes, not all essential nutrients. Choice D is incorrect because during acute diverticulitis, a low-fiber or liquid diet is typically recommended to rest the bowel.

5. A client needs a 24-hour urine collection initiated. Which of the following client statements indicates an understanding of the procedure?

• A. I had a bowel movement, but I was able to save the urine.
• B. I have a specimen in the bathroom from about 30 minutes ago.
• C. I flushed what I urinated at 7 am and have saved the rest since.
• D. I drink a lot, so I will fill up the bottle and complete the test quickly.

Correct answer: C

Rationale: Choice C is correct because it demonstrates the client's understanding of the procedure, which involves discarding the first urine of the day at the specified time and then saving all subsequent urine for the next 24 hours. Choices A, B, and D do not reflect an understanding of the correct procedure. Choice A is incorrect because bowel movements are not part of a 24-hour urine collection. Choice B is incorrect as it does not specify discarding the first urine. Choice D is incorrect as it mentions filling up the bottle quickly, which is not the correct way to collect a 24-hour urine sample.

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