Nursing Elites

1. A nurse has just received change-of-shift report for four clients. Which of the following clients should the nurse assess first?

• A. A client who was just given a glass of orange juice for a low blood glucose level.
• B. A client who is scheduled for a procedure in 1 hr.
• C. A client who has 100 mL fluid remaining in his IV bag.
• D. A client who received a pain medication 30 min ago for postoperative pain.

Correct answer: A

Rationale: The client with low blood glucose needs immediate assessment to ensure that the orange juice has corrected the hypoglycemia. Monitoring the effectiveness of the intervention for low blood glucose is the priority. The other options, such as a client scheduled for a procedure in 1 hour, a client with fluid remaining in the IV bag, and a client who received pain medication 30 minutes ago, do not require immediate assessment like the client with low blood glucose.

2. What is the correct procedure for inserting a nasogastric (NG) tube?

• A. Measure the tube and insert with lubrication
• B. Insert with lubrication and no measurement
• C. Insert without lubrication and secure it
• D. Insert with lubrication and check placement

Correct answer: A

Rationale: The correct procedure for inserting a nasogastric (NG) tube involves measuring the tube to ensure the appropriate length for insertion and using lubrication to reduce discomfort and aid in smooth insertion. Choice B is incorrect as measuring the tube is essential for proper placement. Choice C is incorrect as lubrication helps in easing the insertion process. Choice D is incorrect as checking the placement comes after insertion and should not be done simultaneously with the insertion process.

3. What is the proper technique for administering an intramuscular (IM) injection?

• A. Locate the injection site and insert at 90 degrees
• B. Insert needle at a 45-degree angle
• C. Massage the site after injection
• D. Insert needle at a 15-degree angle

Correct answer: A

Rationale: The correct technique for administering an intramuscular (IM) injection is to locate the injection site and insert the needle at a 90-degree angle. This angle ensures that the medication is delivered into the muscle for proper absorption. Choice B is incorrect because a 45-degree angle is typically used for subcutaneous injections, not intramuscular. Choice C is incorrect as massaging the site after an injection can cause the medication to disperse unevenly. Choice D is incorrect as a 15-degree angle would not reach the muscle layer effectively for an IM injection.

4. What is the process for taking a telephone order from a provider?

• A. Patient name, drug, dose, route, frequency
• B. Read back for accuracy
• C. Have a witness listen to the order
• D. Write down the order and follow up

Correct answer: B

Rationale: The correct process for taking a telephone order from a provider involves reading back the information for accuracy. This step ensures that the order is correctly understood and reduces the risk of errors. While listing patient information (Choice A) is essential, it does not encompass the complete process of verifying the order. Having a witness listen to the order (Choice C) may not always be practical or necessary, as direct verification is more efficient. Writing down the order and following up (Choice D) is not as crucial as the immediate read-back process, which allows for real-time clarification and confirmation.

5. What intervention is key when managing a client with delirium?

• A. Administer antipsychotic medication to calm the client
• B. Identify any reversible causes of delirium
• C. Provide a low-stimulation environment
• D. Increase environmental stimulation

Correct answer: B

Rationale: The correct intervention when managing a client with delirium is to identify any reversible causes. Delirium can be caused by various factors such as infections, medications, dehydration, or metabolic imbalances. Administering antipsychotic medications (Choice A) may worsen delirium and should be avoided unless necessary for specific indications. Providing a low-stimulation environment (Choice C) is beneficial as it can help reduce agitation and confusion in individuals with delirium. Increasing environmental stimulation (Choice D) is contraindicated as it can exacerbate symptoms in delirious patients. Therefore, the priority should be on identifying and addressing reversible causes to effectively manage delirium.

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