Nursing Elites

1. A nurse is completing an incident report about a medication error that she made when she accidentally administered too much insulin to a diabetic client. All of the following are components of this documentation EXCEPT:

• A. The reason for administering the wrong dose
• B. The type of drug involved
• C. The amount of insulin that was given
• D. Any adverse effects on the client

Correct answer: A

Rationale: When completing an incident report for a medication error, it is essential to include factual information such as the type of drug involved, the amount administered, and any adverse effects on the client. However, stating the reason for administering the wrong dose should be avoided in documentation. The focus should be on reporting what happened rather than assigning blame or admitting fault. This approach helps in ensuring a thorough and accurate account of the medication error without introducing subjective elements that could complicate the investigation or resolution process. Therefore, the correct answer is 'The reason for administering the wrong dose.' Choices A, B, and D are vital components of incident report documentation, providing crucial details that help in understanding the error and its impact on the client.

2. A patient is bleeding profusely from an injury near her wrist. Which of the following first aid procedures would be MOST appropriate?

• A. Place a tourniquet on her arm above the injury.
• B. Place pressure on her brachial artery.
• C. Place pressure on her radial nerve.
• D. Cover the bleeding area with wet towels.

Correct answer: B

Rationale: The most appropriate first aid procedure for a patient bleeding profusely from an injury near the wrist is to place pressure on her brachial artery. Applying pressure to the brachial pulse point will help slow down the bleeding. Placing a tourniquet on her arm above the injury is not recommended as it could potentially inhibit blood flow, leading to tissue necrosis. Pressing on the radial nerve or covering the bleeding area with wet towels are not effective in controlling bleeding and may not address the underlying cause.

3. When performing a physical assessment, what technique should the nurse always perform first?

• A. Palpation
• B. Inspection
• C. Percussion
• D. Auscultation

Correct answer: B

Rationale: During a physical assessment, the nurse should always begin with inspection. The sequence of techniques for physical examination is inspection, palpation, percussion, and auscultation. These skills are performed in a specific order, except for the abdominal assessment where auscultation precedes palpation and percussion. Inspection allows the nurse to observe and gather initial information without direct contact. It is a crucial step that provides valuable insights before proceeding to palpation, percussion, and auscultation. Therefore, choice B, 'Inspection,' is the correct answer. Choices A, C, and D are incorrect because they should follow inspection in the sequence of a comprehensive physical assessment.

4. The client often sighs and says in a monotone voice, 'I'm never going to get over this.' When encouraged to participate in care, the client says, 'I don't have the energy.' These cues are suggestive of which nursing diagnoses? Select all that apply.

• A. Hopelessness
• B. Power
• C. Interrupted sleep pattern
• D. Disturbed self-esteem

Correct answer: A

Rationale: A nursing diagnosis involves clinical judgment about a response to a health problem. In this scenario, the client's expressions of feeling overwhelmed and lacking energy indicate feelings of hopelessness and powerlessness. While fatigue is mentioned, there is no direct evidence to support an interrupted sleep pattern, making option C incorrect. Similarly, disturbed self-esteem and self-care deficit are not evident from the given cues, making options D and E incorrect.

5. A client is about to have a TENS unit attached for pain relief. Which of the following actions is most appropriate in this situation?

• A. Inform the client that he may experience tingling sensations.
• B. Connect the TENS unit before the client goes to bed for the night.
• C. Inform the client that the TENS unit may have pain-reducing effects for 10 to 15 days.
• D. After treatment, inform the client that he may not use a TENS unit again for at least 2 weeks.

Correct answer: A

Rationale: When attaching a TENS unit for pain relief, it is essential to inform the client that he may experience tingling sensations. This is a common sensation experienced when using a TENS unit, but it should not cause muscle twitching. The therapeutic effects of a TENS unit usually last between 3 to 5 days. Choice B is incorrect because there is no specific recommendation to connect the TENS unit before bedtime. Choice C is incorrect as stating that the TENS unit may have pain-reducing effects for 10 to 15 days is inaccurate, as the effects typically last 3 to 5 days. Choice D is incorrect because there is no guideline suggesting that the client cannot use a TENS unit again for at least 2 weeks after treatment.

Similar Questions