Nursing Elites

1. A nurse in an emergency department is preparing a change-of-shift report for an adult client who is transferring to a medical-surgical unit using the SBAR communication tool. Which of the following information should the nurse include in the report?

• A. The client has a do-not-resuscitate order.
• B. The client has a continuous IV of lactated Ringer's.
• C. The client was straight catheterized for 350 mL 2 hours ago.
• D. The client has Medicare insurance.

Correct answer: A

Rationale: In an SBAR report, key information such as the client's do-not-resuscitate (DNR) status should be included as it directly impacts the client's care and treatment plan. Choices B and C are important details but may not be as critical for immediate care planning during the shift change. Choice D, the client having Medicare insurance, is important for billing purposes but does not directly impact the client's immediate care needs.

2. Which action should the nurse take to minimize the risk of medication errors?

• A. Prepare medications ahead of time to ensure they are ready.
• B. Ensure two nurses double-check medications before administration.
• C. Administer medications at the same time each day.
• D. Rely on memory to administer the correct medications.

Correct answer: B

Rationale: The correct answer is B because ensuring two nurses double-check medications before administration is a crucial step in minimizing the risk of medication errors. This practice helps in verifying the accuracy of medication orders and reducing the chances of mistakes. Choice A may not necessarily prevent errors as preparing medications ahead of time does not guarantee accuracy. Choice C, administering medications at the same time each day, is important for consistency but does not directly address the risk of errors. Choice D, relying on memory, is highly discouraged as it increases the likelihood of errors due to human forgetfulness.

3. A patient has a new prescription for allopurinol to treat gout. What should the nurse include in the teaching?

• A. Decrease protein intake
• B. Limit salt intake
• C. Increase fluid intake
• D. Limit alcohol

Correct answer: C

Rationale: Correct answer: Increasing fluid intake is essential when taking allopurinol to prevent kidney stones and aid in uric acid excretion. This helps reduce the risk of developing complications associated with gout. Decreasing protein intake (Choice A) is not directly related to allopurinol therapy. Limiting salt intake (Choice B) and alcohol consumption (Choice D) are important for overall health but are not specific recommendations when taking allopurinol for gout.

4. A client is being prepared for discharge after a stroke. Which of the following interventions should be included in the discharge plan to prevent complications?

• A. Recommend physical therapy to improve mobility
• B. Teach the client how to use an incentive spirometer
• C. Encourage the client to ambulate daily
• D. Provide education on proper medication management

Correct answer: D

Rationale: The correct answer is to provide education on proper medication management. Proper medication management is crucial in reducing the risk of stroke recurrence and ensuring the client adheres to the treatment plan. While physical therapy, incentive spirometer use, and daily ambulation are important aspects of stroke rehabilitation, they are not directly related to preventing complications during the discharge phase.

5. A patient has just undergone a tracheostomy. What is the nurse's priority intervention?

• A. Suction the tracheostomy to maintain a patent airway.
• B. Administer pain medication as prescribed.
• C. Change the tracheostomy dressing every 4 hours.
• D. Monitor the patient's oxygen saturation closely.

Correct answer: A

Rationale: The correct answer is to suction the tracheostomy to maintain a patent airway. After a tracheostomy, the priority intervention is to ensure a clear airway to prevent respiratory distress. Administering pain medication, changing the tracheostomy dressing, and monitoring oxygen saturation are important but are secondary to maintaining a patent airway in a patient who has just undergone a tracheostomy.

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