Nursing Elites

1. A nurse manager observes an assistive personnel (AP) incorrectly transferring a client to the bedside commode. Which of the following should the nurse take first?

• A. Refer the AP to the facility procedure manual
• B. Demonstrate the proper client transfer technique for the AP
• C. Instruct the AP to request assistance when unsure about a task
• D. Help the AP assist the client with the transfer

Correct answer: D

Rationale: The correct first action for the nurse is to ensure the safety of the client by immediately intervening to help the AP with the transfer. This hands-on assistance can prevent any potential harm to the client. Referring the AP to the facility procedure manual (Choice A) might take time and delay the necessary immediate action. Demonstrating the proper technique (Choice B) can be done after ensuring the client's safety. Instructing the AP to request assistance (Choice C) is not the most urgent step when a client's safety is at risk.

2. Jansen is receiving metformin (Glucophage). What will be the best plan of the nurse with regard to patient education with this drug? Select one that does not apply.

• A. It stimulates the pancreas to produce more insulin.
• B. It must be taken after meals.
• C. It decreases sugar production in the liver.
• D. It inhibits absorption of carbohydrates.

Correct answer: A

Rationale: The correct choice that does not apply is A. Metformin does not stimulate the pancreas to produce more insulin; instead, it works by decreasing sugar production in the liver, inhibiting carbohydrate absorption, and reducing insulin resistance. It is recommended to take metformin with meals to reduce gastrointestinal side effects. Option B is incorrect as metformin is usually taken with meals. Option D is also incorrect as metformin does not inhibit the absorption of carbohydrates.

3. During which stage of anesthesia is a patient most likely to experience involuntary motor activity?

• A. Stage I
• B. Stage II
• C. Stage III
• D. Stage VI

Correct answer: B

Rationale: The correct answer is Stage II. During Stage II of anesthesia, a patient is most likely to experience involuntary motor activity. This stage is known as the excitement stage, where the patient may exhibit purposeful or involuntary movements. Choice A (Stage I) is incorrect because Stage I is the induction phase where the patient is transitioning from consciousness to unconsciousness, and involuntary motor activity is less likely to occur. Choice C (Stage III) is incorrect as it is the stage of surgical anesthesia characterized by muscle relaxation, and involuntary motor activity is less common during this stage. Choice D (Stage VI) is incorrect as there is no Stage VI in the standard stages of anesthesia. Therefore, the most appropriate stage where involuntary motor activity is likely to occur is Stage II.

4. A nurse working in the emergency department is assessing several clients. Which of the following clients is the highest priority?

• A. A client who reports right-sided flank pain and is diaphoretic
• B. A client who has active bleeding from a puncture wound of the left groin area
• C. A client who has a raised red skin rash on his arms, neck, and face
• D. A client who reports shortness of breath and left neck and shoulder pain

Correct answer: D

Rationale: The correct answer is D because shortness of breath with referred pain may indicate a serious condition, such as a cardiac event or pulmonary embolism, making this the highest priority. Option A, flank pain with diaphoresis, could suggest kidney-related issues but is not as immediately life-threatening as compromised breathing. Option B, active bleeding, though serious, can usually be controlled with proper interventions. Option C, a raised red skin rash, may indicate an allergic reaction but is not as urgent as respiratory distress with neck and shoulder pain.

5. Alcohol, caffeine, or drugs are high-risk factors that all fall under which broad classification of risk factors?

• A. Social demographic
• B. Environmental
• C. Biophysical
• D. Psychosocial

Correct answer: D

Rationale: The correct answer is D: Psychosocial. Alcohol, caffeine, or drug use are considered psychosocial risk factors as they are related to individual behavior, lifestyle choices, and social interactions. Choices A, B, and C are incorrect. Social demographic factors (choice A) refer to characteristics of a population such as age, gender, education, income, etc. Environmental factors (choice B) include physical surroundings like air quality, housing conditions, etc. Biophysical factors (choice C) involve biological aspects like genetics, physiology, and health conditions.

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