Nursing Elites

1. A healthcare professional is preparing to administer a dose of hydrocodone. Which of the following should the healthcare professional assess first?

• A. Respiratory rate
• B. Blood pressure
• C. Pain level
• D. Heart rate

Correct answer: A

Rationale: When administering hydrocodone, a healthcare professional should assess the respiratory rate first because hydrocodone is an opioid that can lead to respiratory depression. Monitoring the respiratory rate helps to detect any signs of respiratory distress or depression early on. Assessing blood pressure, pain level, or heart rate is also important but not the priority when administering hydrocodone, as the risk of respiratory depression is a more critical concern.

2. A nurse is preparing to administer a measles, mumps, and rubella (MMR) vaccine to an adult client. Which of the following is a contraindication to this vaccine?

• A. The possibility of pregnancy within 4 weeks
• B. Client allergy to strawberry
• C. Client history of genital herpes
• D. The possibility of overseas travel in the next month

Correct answer: A

Rationale: The correct answer is A. The MMR vaccine is contraindicated in pregnant women due to the risk of fetal harm. It is recommended that women avoid becoming pregnant for at least 4 weeks after receiving the vaccine. Choice B, client allergy to strawberry, is not a contraindication for the MMR vaccine. Choice C, client history of genital herpes, is not a contraindication for the MMR vaccine. Choice D, the possibility of overseas travel in the next month, is not a contraindication for the MMR vaccine.

3. A charge nurse on a med-surg unit is preparing to delegate tasks to a licensed practical nurse (LPN). What task should the charge nurse delegate to the LPN?

• A. Initiate a care plan.
• B. Perform a complex wound dressing change.
• C. Administer an oral antibiotic to a patient.
• D. Complete an initial assessment.

Correct answer: C

Rationale: The correct task that the charge nurse should delegate to the LPN is to administer an oral antibiotic to a patient. LPNs are trained and permitted to administer medications orally under the supervision of a registered nurse. Initiating a care plan (Choice A) and completing an initial assessment (Choice D) are tasks that typically require higher-level nursing education and critical thinking skills, which are more suitable for registered nurses. Performing a complex wound dressing change (Choice B) involves specialized skills and assessment that are often within the scope of practice of registered nurses or wound care specialists.

4. A nurse is providing discharge instructions to a client following a below-the-knee amputation. Which of the following instructions should the nurse include?

• A. Avoid sitting in a chair for prolonged periods.
• B. Sleep with a pillow under the residual limb.
• C. Elevate the limb continuously for the first 48 hours.
• D. Apply lotion to the residual limb daily.

Correct answer: A

Rationale: The correct answer is to instruct the client to avoid sitting in a chair for prolonged periods. This is important to prevent contractures from developing in the residual limb. Sleeping with a pillow under the residual limb can contribute to contracture formation rather than prevent it. While elevation of the limb is important for reducing swelling and promoting circulation, continuous elevation for 48 hours is not necessary and may not be practical. Applying lotion to the residual limb daily is generally not recommended immediately post-amputation as the wound site needs to heal without interference from lotions or creams.

5. A nurse on a pediatric care unit is delegating client care. Which of the following tasks should the nurse delegate to an assistive personnel?

• A. Initiate a dietary consult for a toddler
• B. Administer a glycerin suppository to a preschool-age child
• C. Evaluate gastric residual following intermittent feeding of an adolescent
• D. Transport a school-age child to x-ray

Correct answer: D

Rationale: The correct answer is D because transporting a stable child to x-ray is a task that can be safely delegated to an assistive personnel. This task does not require clinical judgment or specialized skills. Choices A, B, and C involve assessments and interventions that require nursing judgment and should be performed by a qualified nurse. Initiating a dietary consult for a toddler involves assessing the child's nutritional needs and must be done by a nurse. Administering a glycerin suppository to a preschool-age child requires medication administration skills and knowledge of appropriate dosages, which are within the nurse's scope of practice. Evaluating gastric residual following intermittent feeding of an adolescent is a clinical assessment that requires interpretation and decision-making based on the findings, making it a nursing responsibility.

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