Nursing Elites

1. A nurse is administering medications to a group of clients. Which of the following occurrences requires the completion of an incident report?

• A. A client receives his antibiotics 2 hours late.
• B. A client vomits within 20 minutes of taking his morning medications.
• C. A client requests his statin to be administered at 2100.
• D. A client asks for pain medication 1 hour early.

Correct answer: A

Rationale: The correct answer is A. When a client receives antibiotics 2 hours late, it constitutes a medication error, requiring the completion of an incident report. Choice B, a client vomiting within 20 minutes of taking medications, does not necessarily require an incident report unless it is suspected to be related to a medication error. Choice C, a client requesting a statin at a specific time, and choice D, a client asking for pain medication an hour early, are not incidents that mandate the completion of an incident report unless there are specific circumstances indicating otherwise.

2. A client on glucocorticoid therapy is receiving teaching from a nurse. Which statement by the client indicates an understanding of the teaching?

• A. I have my eyes examined annually.
• B. I take a calcium vitamin supplement daily.
• C. I limit my intake of foods with potassium.
• D. I consistently take my medication between 8 and 9 each evening.

Correct answer: B

Rationale: The correct answer is B. Taking a calcium supplement daily is crucial for clients on glucocorticoid therapy to prevent osteoporosis, a common side effect of long-term use. Choice A is unrelated to glucocorticoid therapy. Choice C, limiting potassium intake, is not necessary for clients on glucocorticoids. Choice D, taking medication consistently in the evening, is important but does not specifically address the side effects of glucocorticoid therapy.

3. A nurse is caring for a client who has a pulmonary embolism. The nurse should identify the effectiveness of the treatment by observing which of the following?

• A. A chest x-ray reveals increased density in all fields
• B. The client reports feeling less anxious
• C. Diminished breath sounds are auscultated bilaterally
• D. ABG results include pH 7.48, PaO2 77 mm Hg, and PaCO2 47 mm Hg

Correct answer: B

Rationale: The correct answer is B because when a client reports feeling less anxious, it suggests that the treatment for a pulmonary embolism is effective. This is a good indicator of the client's overall well-being and response to treatment. Choices A, C, and D are incorrect because a chest x-ray revealing increased density in all fields, diminished breath sounds auscultated bilaterally, and ABG results showing specific values do not directly correlate with the effectiveness of treatment for a pulmonary embolism. While these assessments are important for monitoring the client's condition, the client's subjective report of feeling less anxious provides a more direct insight into the impact of the treatment.

4. A nurse is caring for a client who has Raynaud's disease. Which of the following actions should the nurse take?

• A. Provide information about stress management.
• B. Maintain a warm temperature in the client's room.
• C. Administer epinephrine for acute episodes.
• D. Give glucocorticoid steroids twice a day.

Correct answer: A

Rationale: Corrected Rationale: Providing information about stress management is essential when caring for a client with Raynaud's disease because stress can trigger episodes. Stress management techniques can help the client avoid triggers and reduce the frequency of episodes. Choice B is incorrect because maintaining a warm temperature, rather than a cool one, helps prevent vasoconstriction and can be beneficial for clients with Raynaud's disease. Choice C is incorrect because epinephrine is not a standard treatment for Raynaud's disease; it is more commonly used for severe allergic reactions. Choice D is incorrect because glucocorticoid steroids are not typically used in the management of Raynaud's disease.

5. A client with a colostomy needs optimal skin integrity. What action should the nurse take to promote this?

• A. Cleanse the peristomal skin with alcohol.
• B. Change the colostomy pouch every 3 days.
• C. Use a barrier cream to protect the skin from the pouch contents.
• D. Cleanse the stoma with hydrogen peroxide.

Correct answer: C

Rationale: To promote optimal skin integrity in a client with a colostomy, using a barrier cream to protect the skin from the irritating effects of the colostomy pouch contents is essential. Cleansing the peristomal skin with alcohol (Choice A) can be too harsh and drying for the skin. Changing the colostomy pouch every 3 days (Choice B) is important for hygiene but using a barrier cream is more directly related to skin protection. Cleaning the stoma with hydrogen peroxide (Choice D) is not recommended as it can be too abrasive for the sensitive stoma area.

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