Nursing Elites

1. A nurse is preparing to administer 0.5 mL of oral single-dose liquid medication to a client. Which of the following actions should the nurse take?

• A. Gently shake the container of medication prior to administration
• B. Transfer the medication to a medicine cup
• C. Place the client in a semi-Fowler’s position for medication administration
• D. Verify the dosage by measuring the liquid before administering it

Correct answer: A

Rationale: The correct action for the nurse to take is to gently shake the container of liquid medication before administration. Shaking the container ensures proper mixing of the medication, which is important to maintain uniformity of the dose. Transferring the medication to a medicine cup (choice B) may not be necessary for a small volume like 0.5 mL. Placing the client in a semi-Fowler's position (choice C) is not directly related to administering liquid medication orally. Verifying the dosage by measuring the liquid (choice D) is important but does not address the specific action needed to prepare the medication for administration.

2. A 25-year-old primigravida at 16 weeks gestation is admitted to the hospital with a diagnosis of hyperemesis gravidarum. Which nursing diagnosis should have the highest priority?

• A. Fluid volume deficit
• B. Altered nutrition: less than body requirements
• C. Anxiety related to new situational crisis
• D. Activity intolerance related to fatigue

Correct answer: A

Rationale: In a case of hyperemesis gravidarum, the priority nursing diagnosis should be addressing the Fluid volume deficit. This condition can lead to serious complications such as electrolyte imbalances and dehydration, which can endanger both the mother and the fetus if not managed promptly. Altered nutrition: less than body requirements is important but addressing the fluid volume deficit takes precedence as it poses an immediate threat. Anxiety related to new situational crisis and Activity intolerance related to fatigue are valid concerns, but they are secondary to the critical issue of fluid volume deficit in this scenario.

3. A client is demonstrating postoperative deep breathing and coughing exercises to a client who will have emergency surgery for appendicitis. Which of the following statements indicates a lack of readiness to learn by the client?

• A. The client reports severe pain
• B. The client asks for a demonstration
• C. The client inquires about potential complications
• D. The client agrees to the procedure

Correct answer: A

Rationale: The correct answer is A because severe pain can hinder the client's ability to participate effectively in learning. Pain can be distracting and may prevent the client from focusing on acquiring new information or skills. Choice B is incorrect because asking for a demonstration shows an interest in learning and readiness to understand the exercises. Choice C is incorrect as inquiring about potential complications indicates the client's engagement in understanding the procedure and its outcomes, demonstrating readiness to learn. Choice D is incorrect as agreeing to the procedure does not necessarily reflect a lack of readiness to learn. The client may still be open to receiving information about postoperative care, indicating a level of readiness to learn despite agreeing to the surgery.

4. An older adult client has been hospitalized on bed rest for 1 week. The client reports elbow pain. Which of the following is an appropriate initial action for the nurse caring for this client to take?

• A. Examine the elbow
• B. Administer pain medication
• C. Apply a warm compress to the elbow
• D. Assess the client’s range of motion

Correct answer: A

Rationale: The appropriate initial action for the nurse is to examine the elbow. This step is crucial to assess the site of pain, identify any visible signs of injury or inflammation, and determine the cause of the discomfort. Administering pain medication (Choice B) should come after a thorough assessment. Applying a warm compress (Choice C) might provide temporary relief but does not address the underlying cause. Assessing the client’s range of motion (Choice D) is important but would come after the initial examination to further evaluate the elbow joint.

5. 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 involves physically moving and adjusting their position in bed, which is a task that can be safely delegated to nursing assistive personnel (NAP). This task does not require clinical judgment or assessment skills beyond the ability to follow guidelines for proper positioning. Choices A, C, and D involve assessments or judgments that require a higher level of training and knowledge, making them more appropriate for a nurse to perform. Choice A involves assessing comfort, which may involve subjective factors and individual preferences. Choice C involves identifying hazards related to immobility, which requires understanding the potential risks and complications associated with immobility. Choice D involves assessing circulation, which requires a higher level of clinical knowledge and understanding of circulatory issues.

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