Nursing Elites

1. A nurse in an emergency department is assessing a client who reports ingesting thirty diazepam tablets. After securing the client's airway and initiating an IV, which of the following actions should the nurse do next?

• A. Monitor the client's IV site for thrombophlebitis.
• B. Administer flumazenil to the client.
• C. Evaluate the client for further suicidal behavior.
• D. Initiate seizure precautions for the client.

Correct answer: B

Rationale: Administering flumazenil is the priority to reverse the effects of diazepam overdose. Flumazenil is a specific benzodiazepine receptor antagonist that can rapidly reverse the sedative effects of diazepam. Monitoring the IV site for thrombophlebitis is important but not the immediate priority in this situation. Evaluating the client for further suicidal behavior is important for comprehensive care but is not the most urgent action at this moment. Initiating seizure precautions may be necessary, but the priority is to counteract the sedative effects of diazepam with flumazenil.

2. A healthcare professional is preparing to administer an autologous blood product to a client. Which of the following actions should the healthcare professional take to identify the client?

• A. Match the client's identification band with the number on the blood unit
• B. Confirm the provider's prescription matches the number on the blood component
• C. Ask the client to state their blood type and confirm the date of their last blood donation
• D. Ensure that the client's identification band matches the number on the blood unit

Correct answer: D

Rationale: Ensuring that the client's identification band matches the number on the blood unit is crucial for correct identification. This action helps prevent errors by confirming that the blood product is indeed intended for the specific client. Matching the client's blood type with type and cross-match specimens (Choice A) is important for compatibility but does not directly verify the client's identity. Confirming the provider's prescription (Choice B) is relevant but does not ensure the correct identification of the client. Asking the client to state their blood type and confirm the date of their last blood donation (Choice C) relies on the client's memory and verbal confirmation, which may not be accurate or reliable for identification purposes.

3. What is a crucial nursing responsibility when caring for a patient with a central line?

• A. Flush the line with saline
• B. Monitor for infection
• C. Monitor fluid balance
• D. Replace the central line

Correct answer: B

Rationale: When caring for a patient with a central line, monitoring for infection is a crucial nursing responsibility. This is essential to prevent complications such as bloodstream infections. While flushing the line with saline and monitoring fluid balance are important aspects of care, they are not as critical as monitoring for infection. Replacing the central line is only done when necessary due to complications or at the end of its recommended use.

4. When using an IV pump for a newly admitted client, what action should the nurse take?

• A. Grasp the IV pump cord when unplugging it from the electrical outlet.
• B. Ensure the pump is plugged into an outlet with two prongs.
• C. Hold the IV pump cord while walking the client.
• D. Check for malfunctioning pump alerts.

Correct answer: C

Rationale: The correct action for the nurse to take when using an IV pump for a newly admitted client is to hold the IV pump cord while walking the client. This is important for ensuring the safe and secure management of the IV pump during client mobility. Option A is incorrect as grasping the IV pump cord when unplugging it can lead to electrical hazards. Option B is incorrect as ensuring the pump is plugged into an outlet with two prongs is important for electrical safety but not directly related to the nurse's action. Option D is also important but does not directly address the nurse's immediate action while using the IV pump with the client.

5. A nurse is preparing to administer enoxaparin to a client. Which of the following actions should the nurse take?

• A. Massage the injection site after administration.
• B. Administer the medication intramuscularly.
• C. Inject the medication into the client's abdomen.
• D. Inject the medication into the deltoid muscle.

Correct answer: C

Rationale: The correct answer is to inject the medication into the client's abdomen. Enoxaparin is a medication that should be administered subcutaneously, not intramuscularly. Massaging the injection site after administration is not recommended as it can cause bruising or discomfort. Injecting the medication into the deltoid muscle is also incorrect because enoxaparin should be given in areas of adipose tissue, such as the abdomen, to ensure proper absorption and effectiveness.

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