Nursing Elites

1. A healthcare professional is preparing to administer an intravenous (IV) medication. What action should the healthcare professional take to ensure patient safety?

• A. Ensure the medication is administered at the correct time.
• B. Verify the patient's identification using two identifiers.
• C. Prepare the medication at the healthcare professional's station.
• D. Ensure the medication is administered within 30 minutes of the scheduled time.

Correct answer: B

Rationale: Verifying the patient's identity using two identifiers is crucial to ensure the right patient receives the right medication. This process helps prevent medication errors by confirming the patient's identity through at least two unique identifiers, such as name, date of birth, or medical record number. Choice A is not directly related to ensuring patient safety during medication administration. Choice C is incorrect as medications should be prepared in a sterile environment, not just at the healthcare professional's station. Choice D is not a safe practice as medications should be administered at the scheduled time to maintain therapeutic effectiveness.

2. A client reports difficulty sleeping while in the hospital. Which of the following actions taken by the assistive personnel (AP) while the client is sleeping should prompt the nurse to intervene?

• A. Closes the door to the client's room
• B. Flushes the client's toilet after emptying the urinary catheter's drainage bag
• C. Measures the client's vital signs routinely
• D. Asks a group of personnel in the hall to speak quietly

Correct answer: B

Rationale: The correct answer is B because flushing the client's toilet after emptying the urinary catheter's drainage bag could disturb the client's rest. The nurse should intervene to ensure a restful environment for the client. Choices A, C, and D are not actions that would be disruptive to the client's sleep. Closing the door to the client's room, measuring vital signs routinely, and asking personnel in the hall to speak quietly are appropriate actions that do not directly disturb the client's rest.

3. A nurse enters a client's room and finds the client pulseless. The client's living will requests no resuscitation be performed, but the provider has not written the prescription. Which of the following actions should the nurse take?

• A. Administer emergency medications without performing CPR
• B. Begin CPR
• C. Call the provider for a do-not-resuscitate (DNR) order
• D. Respect the client's wishes, and do not attempt CPR

Correct answer: B

Rationale: The correct action for the nurse to take in this situation is to begin CPR. In the absence of a written DNR order by the provider, the nurse is ethically and legally obligated to initiate CPR to attempt to save the client's life. Administering emergency medications without CPR (Choice A) may not address the immediate need for life-saving measures. Calling the provider for a DNR order (Choice C) may cause a delay in providing necessary resuscitative measures. Respecting the client's wishes and not attempting CPR (Choice D) goes against the nurse's duty to provide immediate life-saving interventions in the absence of a DNR order.

4. 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.

5. A nurse is planning care for an older adult client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin?

• A. Elevate the head of the bed no more than 45 degrees
• B. Apply cornstarch to keep sensitive skin areas dry
• C. Massage the skin over the client's bony prominences
• D. Use a transfer device to lift the client up in bed

Correct answer: D

Rationale: The correct answer is to use a transfer device to lift the client up in bed. This intervention helps reduce friction and the risk of skin breakdown, aiding in the prevention of pressure ulcers. Elevating the head of the bed no more than 45 degrees can help with respiratory issues but does not directly address skin integrity. Applying cornstarch may lead to further skin irritation. Massaging over bony prominences can increase the risk of skin damage rather than maintaining skin integrity.

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