Nursing Elites

1. A nurse is preparing a client for surgery. Which of the following actions should be taken first?

• A. Ensure informed consent is signed
• B. Start IV fluids
• C. Administer preoperative antibiotics
• D. Reinforce surgical site dressing

Correct answer: A

Rationale: The correct answer is to ensure informed consent is signed first when preparing a client for surgery. This step is crucial as it ensures that the client has been informed about the procedure, risks, benefits, and alternatives before giving consent. Starting IV fluids (choice B) may be necessary but comes after obtaining informed consent. Administering preoperative antibiotics (choice C) is important but typically follows confirming informed consent. Reinforcing surgical site dressing (choice D) is a postoperative step and does not take precedence over obtaining informed consent.

2. The nurse is caring for a group of medical-surgical patients. A fire has been reported in an adjacent wing of the hospital. What should the nurse do to ensure the patients' safety?

• A. Wait until the fire department arrives before taking action.
• B. Close all doors.
• C. Identify evacuation routes.
• D. Move bedridden patients in their beds.

Correct answer: B

Rationale: During a fire emergency, it is crucial to close all doors to contain smoke and fire, helping to protect the patients. This action can prevent the spread of fire and smoke to the area where patients are located. Identifying evacuation routes is also important for a timely and orderly evacuation if necessary. Waiting for the fire department to arrive before taking action (Choice A) can waste valuable time and put patients at risk. Moving bedridden patients in their beds (Choice D) can be dangerous during a fire and should be avoided as it can expose patients and staff to more risks.

3. When administering a subcutaneous injection of insulin to a client, what angle should the nurse use for the injection?

• A. 45-degree angle
• B. 60-degree angle
• C. 90-degree angle
• D. 30-degree angle

Correct answer: C

Rationale: The correct angle for administering a subcutaneous injection, such as insulin, is 90 degrees. This angle allows for the medication to be delivered into the subcutaneous layer of tissue beneath the skin. A 45-degree angle is typically used for administering subcutaneous injections in infants or those with reduced adipose tissue, while a 60-degree angle is commonly used for intramuscular injections. A 30-degree angle is not a standard angle for subcutaneous injections.

4. A patient requires repositioning every 2 hours. Which task can the nurse delegate to the nursing assistive personnel?

• A. Determining the level of comfort
• B. Changing the patient's position
• C. Identifying immobility hazards
• D. Assessing circulation

Correct answer: B

Rationale: The correct answer is B: 'Changing the patient's position.' Repositioning the patient every 2 hours can be delegated to nursing assistive personnel as it involves physically moving the patient. Tasks like determining the level of comfort (choice A) and assessing circulation (choice D) are clinical judgments that require a nursing license and should be performed by the nurse. Similarly, identifying immobility hazards (choice C) involves critical thinking and assessment skills that are within the nurse's scope of practice.

5. A patient is admitted with suspected pneumonia. What is the nurse's priority assessment?

• A. Auscultate the patient's lung sounds.
• B. Assess the patient's oxygen saturation.
• C. Monitor the patient's white blood cell count.
• D. Monitor the patient's skin integrity.

Correct answer: B

Rationale: The correct answer is to assess the patient's oxygen saturation. In suspected pneumonia, ensuring adequate oxygenation is critical to monitor respiratory function. Auscultating lung sounds is important but assessing oxygen saturation takes precedence as it directly reflects the patient's oxygen levels. Monitoring white blood cell count is more related to infection assessment rather than immediate respiratory status. Checking skin integrity is essential for overall patient care but is not the priority in a patient with suspected pneumonia.

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