Nursing Elites

1. When documenting client care, which of the following abbreviations should be used?

• A. SS for sliding scale
• B. BRP for bathroom privileges
• C. OJ for orange juice
• D. SQ for subcutaneous

Correct answer: B

Rationale: When documenting client care, it is crucial to use standardized abbreviations to ensure clear communication and prevent misunderstandings. BRP for bathroom privileges is a recognized and commonly used abbreviation in healthcare settings. Choice A, SS for sliding scale, is not a standard abbreviation and can lead to confusion as it could be mistaken for other meanings. Choice C, OJ for orange juice, is informal and may not be universally understood in a healthcare context. Choice D, SQ for subcutaneous, is a valid abbreviation but may not be as relevant in the context of documenting client care compared to BRP, which is more specific and widely accepted.

2. A nurse offers pain medication to a client who is postoperative before ambulation. The nurse understands that this aspect of care delivery is an example of which of the following ethical principles?

• A. Fidelity
• B. Autonomy
• C. Justice
• D. Beneficence

Correct answer: D

Rationale: The correct answer is D: Beneficence. Beneficence involves actions intended to benefit the client, such as providing pain relief. In this scenario, the nurse is demonstrating beneficence by offering pain medication to alleviate the client's discomfort and promote their well-being. Fidelity (A) relates to being faithful to agreements and commitments, autonomy (B) refers to respecting a client's right to make decisions about their care, and justice (C) involves fairness and equal treatment. While these ethical principles are important in healthcare, the situation described primarily exemplifies the principle of beneficence.

3. A nurse is giving a change-of-shift report about a client he admitted earlier that day who has pneumonia. Which of the following pieces of information is the priority for the nurse to provide?

• A. Breath sounds
• B. Client’s history of smoking
• C. Current medication list
• D. Client’s family history of respiratory illness

Correct answer: A

Rationale: In a client with pneumonia, assessing breath sounds is crucial as it provides immediate information about the client's respiratory status. Changes in breath sounds could indicate complications like fluid accumulation or worsening pneumonia. While the client's history of smoking (Choice B), current medication list (Choice C), and family history of respiratory illness (Choice D) are important factors to consider, they are not as urgent or directly related to the client's immediate condition as assessing breath sounds.

4. A nurse on a medical-surgical unit is receiving a change-of-shift report for four clients. Which of the following clients should the nurse see first?

• A. A client who has new onset of dyspnea 24 hours after a total hip arthroplasty
• B. A client who has acute abdominal pain rated 4 on a scale from 0 to 10
• C. A client who has a UTI and low-grade fever
• D. A client who has pneumonia and an oxygen saturation of 96%

Correct answer: A

Rationale: The nurse should prioritize seeing the client who has new onset dyspnea 24 hours after a total hip arthroplasty first. This sudden dyspnea could indicate a serious complication like a pulmonary embolism, which requires immediate assessment and intervention. Acute abdominal pain, a UTI with a low-grade fever, and pneumonia with an oxygen saturation of 96% are important concerns but are not as immediately life-threatening as potential pulmonary embolism indicated by sudden dyspnea postoperatively.

5. The healthcare professional is caring for a client with a chest tube. Which observation requires immediate intervention?

• A. Constant bubbling in the suction control chamber
• B. Intermittent bubbling in the water seal chamber
• C. Drainage of 50 ml per hour
• D. Crepitus around the insertion site

Correct answer: D

Rationale: Crepitus around the chest tube insertion site may indicate subcutaneous emphysema, which requires immediate attention. The presence of crepitus suggests air leaking into the tissues, which could lead to respiratory compromise. Constant bubbling in the suction control chamber is expected and indicates proper functioning of the chest tube system. Intermittent bubbling in the water seal chamber is also normal, showing the system is intact. Drainage of 50 ml per hour is within the expected range for a chest tube.

Similar Questions