Nursing Elites

1. A nurse is supervising a new nursing graduate in various procedures. Which action by the new nursing graduate constitutes a negligent act?

• A. Giving a verbal report to the nurse on the oncoming shift
• B. Checking neurological signs in a client with a head injury
• C. Contacting a healthcare provider about a change in a client's blood pressure
• D. Using clean gloves to change a gastrostomy tube dressing

Correct answer: D

Rationale: Negligent acts in nursing include various errors that can harm the client, such as medication errors, intravenous therapy errors, burns, falls, failure to use aseptic technique, failure to provide adequate monitoring, and failure to report significant changes in a client's condition. In this scenario, using clean gloves to change a gastrostomy tube dressing is a negligent act because sterile gloves should be used when changing a dressing over broken skin. Choices A, B, and C are not negligent acts as they involve appropriate nursing actions: giving a verbal report, checking neurological signs, and contacting a healthcare provider about a change in a client's blood pressure.

2. A nurse is performing suctioning through an adult client's tracheostomy tube. The nurse notes that the client's oxygen saturation is 89% and terminates the procedure. Which action would the nurse take next?

• A. Rechecking the pulse oximetry reading
• B. Calling the respiratory therapist
• C. Calling the healthcare provider
• D. Oxygenating the client with 100% oxygen

Correct answer: D

Rationale: The nurse should monitor the client's heart rate and pulse oximetry during suctioning to assess the client's tolerance of the procedure. Oxygen desaturation to below 90% indicates hypoxemia. If hypoxia occurs during suctioning, the nurse must terminate the procedure and oxygenate the client with 100% oxygen to address the hypoxemia promptly and ensure the client's safety. Rechecking the pulse oximetry reading is important, but the priority is to address the hypoxemia by providing oxygen. Contacting the healthcare provider or respiratory therapist is not necessary at this time as the nurse can manage the hypoxemia with oxygenation. Oxygenating the client with 100% oxygen is the immediate action required in this situation.

3. A nurse is watching as a new nurse employee administers an intramuscular (IM) injection in a client's deltoid muscle. The nurse determines that the new employee is performing the procedure correctly if the new employee uses which technique?

• A. Administers the injection 2 inches below the acromion process
• B. Positions the client with the deltoid muscle exposed
• C. Administers the injection in the thigh
• D. Places the client in the Sims position

Correct answer: A

Rationale: When administering an intramuscular injection in the deltoid muscle, the correct technique involves administering the injection 2 inches below the acromion process, which is the bony structure on top of the shoulder blade. This location ensures safe and effective administration. Administering the injection in the thigh (vastus lateralis or rectus femoris muscle) is not appropriate for a deltoid injection as the deltoid muscle is located in the upper arm. The Sims position is not the correct position for a deltoid muscle injection. While positioning the client with the deltoid muscle exposed allows for proper access and visualization, the critical aspect for a correct deltoid injection is the accurate injection site, 2 inches below the acromion process.

4. A client with which of the following conditions is at risk for developing a high ammonia level?

• A. renal failure
• B. psoriasis
• C. lupus
• D. cirrhosis

Correct answer: D

Rationale: Cirrhosis is the correct answer. In cirrhosis, the liver is unable to detoxify ammonia to urea, leading to an accumulation of ammonia in the blood. This can result in hepatic encephalopathy, a condition characterized by high ammonia levels affecting brain function. Renal failure (Choice A), psoriasis (Choice B), and lupus (Choice C) are not directly associated with an increased risk of high ammonia levels as seen in cirrhosis.

5. The advanced directive in a client's chart is dated August 12, 1998. The client's daughter produces a Power of Attorney for Health Care, dated 2003, which contains different care directions. What should the nurse do?

• A. Follow the 1998 version because it's part of the legal chart.
• B. Follow the 1998 version because the physician's code order is based on it.
• C. Follow the 2003 version, place it in the chart, and communicate the update appropriately.
• D. Follow neither until clarified by the unit manager.

Correct answer: C

Rationale: The document dated 2003 supersedes the previous version and should be used as a basis for care directions. The nurse should follow the 2003 version, place it in the chart, and communicate the update appropriately to ensure that the most current care directions are followed. Choices A and B are incorrect because the 1998 version is now outdated, and the nurse should not rely on it for care decisions. Choice D is incorrect because the nurse should not delay following the updated document, and seeking clarification from the unit manager can lead to avoidable delays in care.

Similar Questions