Nursing Elites

1. A nurse is preparing to administer a medication that requires a peak and trough level. What is the nurse's priority action?

• A. Administer the medication before the peak level is obtained.
• B. Withhold the medication until the trough level is obtained.
• C. Administer the medication based on the previous trough level.
• D. Ensure that the medication is administered within 2 hours of the peak level.

Correct answer: B

Rationale: The nurse's priority action should be to withhold the medication until the trough level is obtained. This is crucial to ensure accurate dosing based on the patient's levels. Administering the medication before the peak level is obtained (choice A) can lead to incorrect dosing. Administering the medication based on the previous trough level (choice C) may not reflect the current levels accurately. Ensuring that the medication is administered within 2 hours of the peak level (choice D) is not necessary for obtaining accurate peak and trough levels.

2. A charge nurse on a medical-surgical unit is preparing to delegate tasks to a licensed practical nurse (LPN). Which of the following tasks should the charge nurse delegate to the LPN?

• A. Administering an oral antibiotic to a client
• B. Performing an admission assessment of a client
• C. Creating new teaching for a guardian of a toddler
• D. Administering IV conscious sedation to a client

Correct answer: A

Rationale: Administering oral antibiotics is within the scope of practice for an LPN and can be safely delegated. LPNs are trained to administer medications, including oral ones. Performing an admission assessment (Choice B) involves critical thinking and comprehensive evaluation, typically done by registered nurses. Creating new teaching material (Choice C) requires specialized knowledge and is usually the responsibility of a nurse with additional training in education. Administering IV conscious sedation (Choice D) is a high-risk task that requires advanced skills and should be performed by a registered nurse or higher-level provider.

3. A nurse is observing a patient's use of a walker. Which observation indicates a need for further teaching?

• A. The patient advances the walker too far ahead.
• B. The patient uses the walker to assist in standing.
• C. The patient maintains their balance while using the walker.
• D. The patient walks with their back hunched over.

Correct answer: A

Rationale: The correct answer is A because advancing the walker too far ahead increases the risk of falls, indicating a need for further teaching. Choice B is correct as using the walker to assist in standing is a proper use. Choice C is correct as maintaining balance while using the walker shows proper technique. Choice D is incorrect as walking with the back hunched over is a posture issue, not directly related to walker use.

4. A nurse manager is implementing a quality improvement project to reduce the number of methicillin-resistant Staphylococcus aureus (MRSA) infections at the facility. Which of the following actions should the nurse manager take first?

• A. Develop an MRSA protocol for implementation.
• B. Provide educational in-services for staff.
• C. Evaluate outcomes resulting from interventions.
• D. Conduct a chart review to evaluate precipitating factors of clients who develop MRSA.

Correct answer: D

Rationale: Conducting a chart review to evaluate the precipitating factors of clients who develop MRSA is the initial step in reducing these infections. By identifying factors contributing to MRSA infections, the nurse manager can develop targeted interventions. Developing an MRSA protocol (choice A) and providing educational in-services (choice B) would be premature without understanding the specific factors at play. Evaluating outcomes (choice C) should come after implementing interventions based on the findings from the chart review.

5. A nurse manager assigns a new nurse to care for a client with unstable blood pressure. What is the nurse's priority action?

• A. Ask the charge nurse for assistance.
• B. Recheck the blood pressure before calling for help.
• C. Monitor the client's blood pressure closely.
• D. Administer antihypertensive medication immediately.

Correct answer: B

Rationale: The correct answer is to recheck the blood pressure before calling for help. When caring for a client with unstable blood pressure, the nurse's priority is to ensure an accurate assessment. Rechecking the blood pressure will confirm the instability and guide further actions. Asking the charge nurse for assistance (Choice A) is important but should come after assessing the situation. Monitoring the client's blood pressure closely (Choice C) is essential, but the immediate action should be to recheck and confirm the current status. Administering antihypertensive medication immediately (Choice D) without a confirmed assessment can be dangerous and is not the initial priority.

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