Nursing Elites

1. A nurse manager is reviewing documentation with a newly licensed nurse. Which of the following notations by the newly licensed nurse indicates an understanding of the teaching?

• A. ''OOB with assistance for breakfast''
• B. ''Given 2 mg MSO4 IM for report of pain''
• C. ''Dressing changed qd''
• D. ''Administered 8 units of regular insulin subcutaneously''

Correct answer: D

Rationale: The correct answer demonstrates proper documentation by specifying the action taken ('Administered'), the dose ('8 units'), the medication ('regular insulin'), and the route of administration ('subcutaneously'). This notation ensures clarity and accuracy in recording the nursing intervention, aligning with best practices in documentation.

2. A client has had a cast applied, and a nurse is providing care. Which of the following actions should the nurse take first?

• A. Place an ice pack over the cast.
• B. Palpate the pulse distal to the cast.
• C. Teach the client to keep the cast clean and dry.
• D. Position the casted extremity on a pillow.

Correct answer: B

Rationale: When caring for a client with a newly applied cast, the nurse's priority should be to assess the circulation by palpating the pulse distal to the cast. This is crucial to ensure there is no compromise in blood flow, which could lead to serious complications. Placing an ice pack over the cast, teaching the client about cast care, and positioning the casted extremity on a pillow are important interventions but should follow the assessment of circulation.

3. Which of the following measures is not recommended to prevent pressure ulcers?

• A. Massaging the reddened area with lotion
• B. Using a water or air mattress
• C. Adhering to a schedule for positioning and turning
• D. Providing meticulous skin care

Correct answer: A

Rationale: Massaging a reddened area can cause further tissue damage by increasing pressure on already compromised skin. The other options, such as using specialized mattresses, adhering to repositioning schedules, and maintaining good skin care, are all recommended strategies to prevent pressure ulcers by reducing pressure and friction on vulnerable areas of the skin.

4. Which of the following interventions promotes patient safety?

• A. Assess the patient’s ability to ambulate and transfer from a bed to a chair
• B. Demonstrate the signal system to the patient
• C. Check to see that the patient is wearing their identification band
• D. All of the above

Correct answer: D

Rationale: All the listed interventions are essential for promoting patient safety. Assessing the patient’s ability to ambulate and transfer helps prevent falls, demonstrating the signal system ensures effective communication in emergencies, and checking the patient's identification band aids in accurate identification and treatment. By combining these interventions, healthcare providers can enhance patient safety and quality of care.

5. A client experiencing acute dyspnea and diaphoresis reports anxiety and difficulty breathing. Vital signs include HR 117/min, respirations 38/min, temperature 38.4 C (101.2 F), and blood pressure 100/54 mm Hg. What should the nurse prioritize?

• A. Notify the provider.
• B. Administer heparin via IV infusion.
• C. Administer oxygen therapy.
• D. Obtain a spiral CT scan.

Correct answer: C

Rationale: In a client with acute dyspnea, diaphoresis, tachycardia, tachypnea, fever, and hypotension, the priority is to ensure adequate oxygenation. Administering oxygen therapy helps improve oxygenation levels and stabilize the client's condition. This intervention takes precedence over notifying the provider, administering heparin, or obtaining a CT scan, as oxygen therapy addresses the client's immediate need for respiratory support.

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