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. Which of the following actions is most appropriate for reducing the risk of infection during the post-operative period?

• A. Flush the central line with heparin at least every four hours
• B. Administer narcotic analgesics as needed
• C. Remove the urinary catheter as soon as the client is ambulatory
• D. Order a high-protein diet for the client

Correct answer: C

Rationale: The most appropriate action to reduce the risk of infection during the post-operative period is to remove the urinary catheter as soon as the client is ambulatory. Urinary catheters can serve as a source of bacteria, increasing the risk of infection in the bladder or urethra. By removing the catheter promptly once the client is mobile, the risk of infection can be minimized. Option A, flushing the central line with heparin, is not directly related to reducing urinary tract infections. Option B, administering narcotic analgesics as needed, is important for pain management but does not directly address infection prevention. Option D, ordering a high-protein diet, may be beneficial for wound healing but does not specifically target infection risk reduction in the post-operative period.

3. The nurse supervises unlicensed assistive personnel (UAP) who are providing care for a patient with right lower lobe pneumonia. The nurse should intervene if which action by UAP is observed?

• A. UAP splint the patient's chest during coughing.
• B. UAP assist the patient to ambulate to the bathroom.
• C. UAP help the patient to a bedside chair for meals.
• D. UAP lower the head of the patient's bed to 15 degrees.

Correct answer: D

Rationale: The correct action for the nurse to intervene in is when the UAP lowers the head of the patient's bed to 15 degrees. This position can decrease ventilation in a patient with pneumonia, potentially worsening their condition. Choices B and C involve assisting the patient with activities of daily living and promoting mobility, which are appropriate for the patient's care. Choice A, splinting the patient's chest during coughing, can help the patient manage coughing effectively, which is also appropriate for a patient with pneumonia.

4. During an examination of a patient's abdomen, the nurse notes that the abdomen is rounded and firm to the touch. During percussion, the nurse notes a drum-like quality of the sounds across the quadrants. How would the nurse interpret this type of sound?

• A. Constipation
• B. Air-filled areas
• C. Presence of a tumor
• D. Presence of dense organs

Correct answer: B

Rationale: A musical or drum-like sound (tympany) is heard when percussion occurs over an air-filled viscus, such as the stomach or intestines. This indicates the presence of air-filled areas. Constipation, choice A, does not produce specific percussion sounds and is related to bowel movements rather than the sound produced during percussion. The presence of a tumor, choice C, would not typically produce a drum-like sound but might result in dullness or decreased resonance. Dense organs, choice D, would produce a dull thud sound rather than a drum-like tympanic sound.

5. Which of the following lists the recommended sequence for removing soiled personal protective equipment when preparing to leave a patient's room?

• A. Gown, goggles, mask, gloves, and exit the room.
• B. Gloves, wash hands, remove gown, mask, and goggles.
• C. Gloves, goggles, gown, mask, and wash hands.
• D. Gloves, goggles, gown, mask, and wash hands.

Correct answer: D

Rationale: The correct sequence for removing soiled personal protective equipment is crucial to prevent contamination. Gloves should always be removed first as they are most likely to be contaminated. Following the removal of gloves, goggles, gown, mask, and finally washing hands is recommended. Choice A is incorrect as gloves should be removed first. Choice B is incorrect as the sequence is not in the recommended order. Choice D is incorrect as gloves should be removed before goggles.

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