Nursing Elites

1. A nurse on a surgical unit is receiving a client who had abdominal surgery from the postanesthesia care unit. Which of the following assessments should the nurse make first?

• A. Airway
• B. Blood pressure
• C. Surgical site
• D. Level of consciousness

Correct answer: A

Rationale: The correct answer is to assess the airway first. Ensuring a clear and patent airway is crucial to maintaining adequate oxygenation and ventilation post-surgery. Assessing the airway takes precedence over other assessments as a compromised airway can lead to hypoxia and respiratory distress. Checking blood pressure, the surgical site, or level of consciousness are important but are secondary to ensuring the airway is clear and the client can breathe effectively.

2. During a staff meeting, a nurse is discussing the purpose of regulatory agencies. Which of the following tasks should the nurse identify as the responsibility of state licensing boards?

• A. Monitoring evidence-based practice for clients with specific diagnoses.
• B. Ensuring that health care providers comply with regulations.
• C. Setting quality standards for accrediting health care facilities.
• D. Determining the safety of medications for administration to clients.

Correct answer: B

Rationale: State licensing boards are primarily responsible for ensuring that health care providers comply with regulations. This includes overseeing licensure requirements, investigating complaints, and enforcing disciplinary actions. Monitoring evidence-based practice for clients with specific diagnoses is typically within the domain of professional organizations or healthcare institutions. Setting quality standards for accrediting health care facilities is usually the role of accrediting bodies such as The Joint Commission. Lastly, determining the safety of medications for administration to clients falls under the purview of regulatory agencies like the Food and Drug Administration (FDA).

3. When a client files a lawsuit against an LPN for malpractice, the client must prove that there is a link between the harm suffered and actions performed by the nurse that were negligent. This is known as:

• A. Evidence
• B. Tort discovery
• C. Proximate cause
• D. Common cause

Correct answer: C

Rationale: The correct answer is C, 'Proximate cause.' Proximate cause establishes the link between the harm suffered and the negligent actions performed by the nurse. In a malpractice lawsuit, proving proximate cause is essential to demonstrate that the nurse's actions directly led to the harm experienced by the client. Choice A, 'Evidence,' is incorrect as evidence is the information presented to support or refute a claim, not specifically the link between harm and negligence. Choice B, 'Tort discovery,' is incorrect as it does not specifically refer to establishing the link between harm and negligence. Choice D, 'Common cause,' is incorrect as it does not capture the legal concept of proximate cause in establishing liability in malpractice cases.

4. A client has a new prescription for nitroglycerin sublingual tablets. Which of the following instructions should the nurse include?

• A. Take the medication with food.
• B. Place the tablet under your tongue and let it dissolve completely.
• C. Swallow the tablet whole with a glass of water.
• D. Chew the tablet for faster relief.

Correct answer: B

Rationale: The correct instruction for a client prescribed nitroglycerin sublingual tablets is to place the tablet under the tongue and let it dissolve completely. This route of administration allows for rapid absorption of the medication through the oral mucosa, providing quick relief for angina symptoms. Option A, taking the medication with food, is incorrect as nitroglycerin should be taken sublingually, not with food. Option C, swallowing the tablet whole with water, is incorrect as sublingual tablets should not be swallowed whole. Option D, chewing the tablet for faster relief, is also incorrect as chewing the tablet can lead to rapid absorption and potential adverse effects rather than a controlled release for angina relief.

5. After preparing and lubricating the enema set, what is the correct sequence of steps a nurse should follow when administering a large volume enema to a client?

• A. Administer the enema solution.
• B. Remove the enema tube from the client's rectum.
• C. Wrap the end of the enema tube with a disposable tissue.
• D. Insert the enema tube into the client's rectum.

Correct answer: B

Rationale: The correct sequence for administering a large volume enema is as follows: 1. Insert the enema tube into the rectum, 2. Administer the enema solution, 3. Clamp the tube, 4. Remove the tube, 5. Wrap the end with tissue. Therefore, the nurse should remove the enema tube from the client's rectum after administering the enema solution. Choices A, C, and D are incorrect because the enema tube should be removed from the rectum after the administration of the solution, not before or during the process.

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