Nursing Elites

1. When developing an educational program for staff regarding a new intravenous pump, what is the correct sequence of actions for a nurse to take?

• A. Develop learning objectives for the program
• B. Identify what skills to teach the staff members
• C. Conduct program evaluation with staff members
• D. Schedule several sessions of the program

Correct answer: B

Rationale: The correct sequence of actions when developing an educational program for staff regarding a new intravenous pump is to first identify what skills to teach the staff members. This step is essential as it sets the foundation for the learning objectives to be developed next. Once the learning objectives are established, scheduling several sessions of the program can be planned accordingly. Finally, after the program has been conducted, program evaluation with staff members should take place to assess the effectiveness of the educational program. Therefore, options A, C, and D are out of sequence, making them incorrect choices.

2. You are performing a neurological assessment of your adolescent patient. The patient has the Moro reflex. How should you interpret this neurological assessment finding?

• A. It is normal among adolescents.
• B. It indicates that the patient has an intact peripheral nervous system.
• C. It indicates that the patient has an intact central nervous system.
• D. It is not a normal finding.

Correct answer: D

Rationale: The Moro reflex, also known as the startle reflex, is typically present in infants up to around 4-6 months of age and is characterized by the infant's response to a sudden loss of support or loud noise. It is not a normal finding in adolescents or older individuals. Therefore, if an adolescent patient exhibits the Moro reflex during a neurological assessment, it is considered abnormal and warrants further evaluation. Choices A, B, and C are incorrect because the Moro reflex is not expected or normal among adolescents and does not specifically indicate the status of either the peripheral or central nervous system in this age group.

3. A charge nurse is making staff assignments on a medical-surgical unit. Which of the following tasks should the nurse plan to delegate to an assistive personnel?

• A. Measuring oxygen saturation for a client who has dyspnea
• B. Inserting a rectal suppository for a client who is vomiting
• C. Performing nasal hygiene for a client who has an NG tube
• D. Pouching a client's ostomy bag for a new colostomy

Correct answer: D

Rationale: Pouching a new colostomy is a task that can be safely and appropriately delegated to an assistive personnel as it falls within their scope of practice. Measuring oxygen saturation (Choice A) requires a higher level of training and assessment, making it unsuitable for delegation. Inserting a rectal suppository (Choice B) and performing nasal hygiene (Choice C) involve invasive procedures that are typically performed by licensed nursing staff due to the associated risks and complexities, making them inappropriate for delegation to assistive personnel.

4. A charge nurse making rounds observes that an assistive personnel (AP) has applied wrist restraints to a client who is agitated and does not have a prescription for restraints. Which of the following actions should the nurse take first?

• A. Remove the restraints from the client's wrists
• B. Review the chart for nonrestraint alternatives for agitation
• C. Speak with the AP about the incident
• D. Inform the unit manager of the incident

Correct answer: A

Rationale: The correct action for the nurse to take first is to remove the restraints from the client's wrists. Restraints should not be applied without a prescription due to the risk of harm to the client. Removing the restraints promptly is a priority to ensure the client's safety. Reviewing nonrestraint alternatives, speaking with the AP, and informing the unit manager can follow after ensuring the client's immediate safety by removing the restraints.

5. What does the mnemonic device ABCDE stand for?

• A. Allergy, bleeding, chemicals, dietary, environment
• B. Allergy, bleeding, cardio, diabetes, endocrine
• C. Allergy, bleeding, cardio, digestive, endocrine
• D. Allergy, bleeding, cortisone, diabetes, emboli

Correct answer: D

Rationale: The correct answer is D: 'Allergy, bleeding, cortisone, diabetes, emboli.' The ABCDE mnemonic is used in healthcare to help remember key assessment points. Choice A is incorrect as 'chemicals' and 'dietary' are not part of the ABCDE assessment. Choice B is incorrect as 'cardio' is not part of the ABCDE mnemonic. Choice C is incorrect as 'cardio' and 'digestive' are not part of the ABCDE mnemonic.

Similar Questions