Nursing Elites

1. A nurse is reviewing the laboratory report of a client who has been receiving lithium carbonate for the past 12 months. The nurse notes a lithium level of 0.8 mEq/L. Which of the following orders from the provider should the nurse expect?

• A. Withhold the next dose.
• B. Increase the dosage.
• C. Discontinue the medication.
• D. Administer the medication.

Correct answer: D

Rationale: Administering the medication is appropriate for a stable lithium level of 0.8 mEq/L. A level of 0.8 mEq/L falls within the therapeutic range for lithium, indicating that the client is receiving an adequate dose to maintain therapeutic effects. Withholding the next dose, increasing the dosage, or discontinuing the medication would not be indicated at this lithium level as it is within the desired range for therapeutic benefit. Therefore, the correct action would be to continue administering the medication to ensure the client maintains the therapeutic level of lithium.

2. When digitally evacuating stool from a client with a fecal impaction, what action should the nurse take?

• A. Insert a lubricated gloved finger and advance along the rectal wall
• B. Apply lubricant and stimulate peristalsis
• C. Apply pressure to the abdomen to assist with the removal
• D. Increase fluid intake before the procedure

Correct answer: A

Rationale: The correct action when digitally evacuating stool from a client with a fecal impaction is to insert a lubricated gloved finger and advance along the rectal wall. This technique helps prevent trauma and is the appropriate method for addressing fecal impaction. Choice B is incorrect as stimulating peristalsis will not directly assist in evacuating the impacted stool. Choice C is incorrect as applying pressure to the abdomen is not the recommended method for stool evacuation. Choice D is incorrect as increasing fluid intake does not directly aid in digitally evacuating the stool.

3. A charge nurse is educating a group of unit nurses about delegating client tasks to assistive personnel. Which of the following statements should the nurse make?

• A. The nurse is legally responsible for the actions of the AP.
• B. An AP can perform tasks outside of their scope if they have been trained.
• C. An experienced AP can delegate tasks to another AP.
• D. An RN evaluates the client's needs to determine tasks to delegate.

Correct answer: D

Rationale: The correct statement is D: 'An RN evaluates the client's needs to determine which tasks are appropriate to delegate to assistive personnel.' This is an essential step in the delegation process to ensure that tasks are assigned appropriately based on the client's condition and the competencies of the assistive personnel. Option A is incorrect because while the nurse retains accountability for delegation decisions, the AP is responsible for their actions. Option B is incorrect as tasks should be within the AP's scope of practice regardless of training. Option C is incorrect as delegation typically involves assigning tasks from the RN to the AP, not between APs.

4. How should a healthcare professional administer a subcutaneous injection?

• A. Insert the needle at a 45-degree angle
• B. Insert the needle at a 90-degree angle
• C. Use a Z-track method
• D. Insert the needle at a 15-degree angle

Correct answer: A

Rationale: The correct technique for administering subcutaneous injections is to insert the needle at a 45-degree angle. This angle ensures that the medication is delivered into the subcutaneous tissue, which is located just below the skin. Inserting the needle at a 90-degree angle is more appropriate for intramuscular injections, while using a Z-track method is specific to intramuscular injections to prevent leakage of medication into the subcutaneous tissue. Inserting the needle at a 15-degree angle would not reach the subcutaneous tissue effectively.

5. A nurse is caring for a client who is 24 hr postpartum and is breastfeeding her newborn. The client asks the nurse to warm up seaweed soup that her partner brought for her. Which of the following responses should the nurse make?

• A. Does the doctor know you are eating that?
• B. Why are you eating seaweed soup?
• C. Of course, I will heat that up for you.
• D. The hospital food is more nutritious.

Correct answer: C

Rationale: Respecting cultural preferences and providing client-centered care promotes trust.

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