Nursing Elites

1. A client has a closed wound drainage system. Which of the following actions should the nurse take?

• A. Avoid pressing the container down to create a vacuum
• B. Wear sterile gloves while handling the drainage system
• C. Reset the container with the drainage port closed
• D. Maintain the drain in a dependent position to facilitate drainage

Correct answer: D

Rationale: In a closed wound drainage system, it is essential to maintain the drain in a dependent position to allow for proper drainage. Gravity aids in the flow of drainage, preventing fluid backflow or pooling. Avoiding pressing the container down to create a vacuum (Choice A) is crucial as it can lead to complications in the system. Wearing sterile gloves (Choice B) is important for infection control when handling the drainage system. Resetting the container with the drainage port closed (Choice C) is incorrect as it can cause spillage and contamination of the surrounding area.

2. When orienting a newly licensed nurse on taking a telephone prescription, which statement indicates understanding of the process?

• A. A second nurse enters the prescription into the client’s medical record.
• B. Another nurse should listen to the phone call.
• C. The provider can clarify the prescription when they sign the health record.
• D. I should omit the 'read back' if this is a one-time prescription.

Correct answer: A

Rationale: The correct answer is A because a second nurse should verify and enter the prescription into the client’s medical record to ensure accuracy. This step is crucial to prevent errors in transcription and administration. Choice B is incorrect as having another nurse listen to the phone call does not ensure accurate transcription. Choice C is incorrect because the provider clarifying the prescription upon signing the health record does not replace the need for proper documentation. Choice D is incorrect because the 'read back' process is essential for all telephone prescriptions to confirm accuracy and prevent errors in transcription or administration.

3. A nurse on a surgical unit is receiving a client who had abdominal surgery from the postanesthesia care unit. Which of the following assessments should the nurse make first?

• A. Airway
• B. Blood pressure
• C. Surgical site
• D. Level of consciousness

Correct answer: A

Rationale: The correct answer is to assess the airway first. Ensuring a clear and patent airway is crucial to maintaining adequate oxygenation and ventilation post-surgery. Assessing the airway takes precedence over other assessments as a compromised airway can lead to hypoxia and respiratory distress. Checking blood pressure, the surgical site, or level of consciousness are important but are secondary to ensuring the airway is clear and the client can breathe effectively.

4. The healthcare provider is caring for a patient with a spinal cord injury and notices that the patient's hips have a tendency to rotate externally when the patient is supine. Which device will the healthcare provider use to help prevent injury secondary to this rotation?

• A. Hand rolls
• B. A trapeze bar
• C. A trochanter roll
• D. Hand-wrist splints

Correct answer: C

Rationale: A trochanter roll is the correct choice as it is used to prevent external rotation of the hips when the patient is in a supine position. Hand rolls (Choice A) are incorrect because they are used to prevent contractures of the fingers, wrist, and hand. A trapeze bar (Choice B) is not the correct option as it helps patients change positions in bed and aids with movement, not specifically for hip rotation. Hand-wrist splints (Choice D) are also incorrect as they are used to maintain the functional position of the wrist and hand, not to address hip rotation.

5. Postoperatively, signs of hemorrhagic shock are observed. The nurse notifies the surgeon, who instructs to continue monitoring vitals every 15 minutes and report back in one hour. What should the nurse do next?

• A. Notify the nurse manager
• B. Continue monitoring as instructed
• C. Administer IV fluids as per protocol
• D. Prepare for immediate transfer to the ICU

Correct answer: B

Rationale: The correct answer is to continue monitoring the patient as instructed. This is crucial to assess the patient's condition and response to initial interventions. Administering IV fluids or preparing for transfer to the ICU should only be done based on further assessment or explicit orders from the healthcare provider. Notifying the nurse manager, as suggested in choice A, without further assessment or intervention could delay immediate patient care and management.

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