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 best way to assess for fluid overload in a patient with heart failure?

• A. Check daily weight
• B. Check blood pressure
• C. Monitor heart sounds
• D. Assess for jugular vein distention

Correct answer: A

Rationale: The correct answer is to 'Check daily weight.' Monitoring daily weight is the most accurate method to assess for fluid overload in patients with heart failure. Weight gain can indicate fluid retention, a common issue in heart failure patients. Checking blood pressure (Choice B) can provide information about hemodynamic status but may not be as specific for fluid overload as monitoring weight. Monitoring heart sounds (Choice C) can provide information about cardiac function but may not directly assess fluid overload. Assessing for jugular vein distention (Choice D) can be a sign of increased central venous pressure but may not always correlate with fluid overload as accurately as daily weight checks.

3. A client who is postoperative following a total hip arthroplasty is at risk for hip dislocation. Which of the following actions should the nurse take to prevent this complication?

• A. Position the client supine with a pillow between the legs
• B. Place a pillow under the client's knees
• C. Place an abduction pillow between the client's legs
• D. Place a trochanter roll under the client's legs

Correct answer: C

Rationale: After a total hip arthroplasty, it is crucial to prevent hip dislocation. Placing an abduction pillow between the client's legs helps maintain proper alignment and prevents the hip from dislocating. This position aids in keeping the hip in a neutral or slightly outwardly rotated position, reducing the risk of dislocation. Placing the client supine with a pillow between the legs (Choice A) or using a trochanter roll (Choice D) may not provide the same level of abduction and support needed to prevent hip dislocation. Placing a pillow under the client's knees (Choice B) does not provide the necessary support to maintain proper hip alignment in this situation.

4. A nurse is caring for a client who has right-sided heart failure. Which of the following findings should the nurse expect?

• A. Peripheral edema.
• B. JVD.
• C. Crackles in the lungs.
• D. Hypotension.

Correct answer: B

Rationale: The correct answer is B: JVD. Jugular venous distention (JVD) is a common finding in right-sided heart failure due to fluid overload. This occurs because the right side of the heart is unable to effectively pump blood, leading to congestion and increased venous pressure, which is manifested as JVD. Choices A, C, and D are incorrect. Peripheral edema (choice A) is more commonly associated with left-sided heart failure. Crackles in the lungs (choice C) are indicative of pulmonary edema, often seen in left-sided heart failure. Hypotension (choice D) is not typically seen in right-sided heart failure, as it is more commonly associated with conditions like shock or severe dehydration.

5. A client who has a new diagnosis of type 2 diabetes mellitus is being taught about foot care by a nurse. Which of the following statements should the nurse include?

• A. Use lotion on your feet to prevent dry, cracked skin, avoiding application between the toes.
• B. Avoid soaking your feet in warm water daily to prevent dry skin.
• C. Trim your toenails straight across to prevent injury.
• D. Do not apply a heating pad to your feet if they feel cold.

Correct answer: C

Rationale: The correct answer is C. Trimming toenails straight across is essential for clients with diabetes to prevent the risk of ingrown toenails and injury. Using lotion on feet can be beneficial but should not be applied between the toes to avoid moisture buildup, which can lead to infections. Soaking feet in warm water can lead to dry skin, increasing the risk of cracks and other complications. Applying a heating pad to feet when they feel cold is not recommended for clients with diabetes due to impaired sensation, which can result in burns and other injuries.

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