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 antibiotics 2 hours late.
• B. A client vomits within 20 minutes of taking morning medications.
• C. A client requests a 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. Administering antibiotics late must be reported as it can compromise the effectiveness of the treatment. This delay can lead to subtherapeutic levels of the antibiotic in the client's system, potentially reducing its efficacy in combating the infection. Choice B, a client vomiting shortly after taking medication, should be noted but does not necessarily require an incident report unless it is a frequent occurrence. It could indicate a possible adverse reaction or intolerance to the medication. Choice C, a client requesting a statin at a specific time, and choice D, a client asking for pain medication slightly earlier, do not involve medication errors or deviations that pose immediate risks to the client's health, so they do not require incident reports.

2. What is the most appropriate nursing intervention for a patient with suspected deep vein thrombosis (DVT)?

• A. Administer anticoagulants
• B. Apply compression stockings
• C. Encourage ambulation
• D. Monitor oxygen saturation

Correct answer: A

Rationale: The correct answer is A: Administer anticoagulants. Administering anticoagulants is the most appropriate nursing intervention for a patient with suspected DVT because it helps prevent further clot formation and complications. Applying compression stockings (choice B) can be a preventive measure but is not the primary intervention for treating DVT. Encouraging ambulation (choice C) is beneficial for preventing DVT but is not the immediate intervention for a suspected case. Monitoring oxygen saturation (choice D) is important for assessing respiratory function but is not the primary intervention for DVT treatment.

3. A nurse is teaching a newly licensed nurse about ergonomic principles. Which of the following actions by the nurse indicates an understanding of the teaching?

• A. Stands with feet shoulder-width apart when lifting a client up in bed.
• B. Raises the client's knees before pulling the client up in bed.
• C. Uses a mechanical lift to move a client from bed to chair.
• D. Places a gait belt around the client's waist before assisting the client to stand.

Correct answer: C

Rationale: Using a mechanical lift is an appropriate ergonomic technique as it reduces the risk of injury to both the nurse and the client by promoting safe client handling practices. Choice A is incorrect as standing with feet shoulder-width apart provides better balance and stability during lifting. Choice B is incorrect as raising the client's knees is not directly related to ergonomic principles. Choice D is incorrect as placing a gait belt around the client's waist is a safety measure but does not specifically demonstrate an understanding of ergonomic principles.

4. A nurse is caring for a client who is receiving oxytocin to augment labor. The client's contractions are occurring every 90 seconds with a duration of 90 seconds. Which of the following actions should the nurse take?

• A. Increase oxytocin infusion.
• B. Decrease oxytocin infusion.
• C. Maintain oxytocin infusion.
• D. Discontinue oxytocin infusion.

Correct answer: D

Rationale: The correct action for the nurse to take in this scenario is to discontinue the oxytocin infusion. With contractions occurring every 90 seconds with a duration of 90 seconds, the contractions are too frequent and prolonged, which can lead to uterine rupture or fetal distress. Increasing or maintaining the oxytocin infusion would exacerbate the situation, potentially causing harm to the mother and fetus. Decreasing the oxytocin infusion might not be sufficient to address the issue, making discontinuation the most appropriate action to ensure the safety of both the client and the baby.

5. A nurse is caring for a client who has a new diagnosis of tuberculosis (TB). Which of the following interventions should the nurse include in the plan of care?

• A. Place the client in a private room with negative airflow.
• B. Wear an N95 respirator when caring for the client.
• C. Place the client in a positive pressure room.
• D. Maintain the client on droplet precautions.

Correct answer: A

Rationale: The correct answer is to place the client in a private room with negative airflow. This is crucial for preventing the spread of tuberculosis (TB) infection. Option B, wearing an N95 respirator when caring for the client, is important for staff protection but does not address the need for isolation precautions. Option C, placing the client in a positive pressure room, is incorrect as TB clients should be in negative pressure rooms to prevent the spread of airborne pathogens. Option D, maintaining the client on droplet precautions, is not sufficient for TB, which requires airborne precautions.

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