Nursing Elites

1. A patient is admitted and is placed on fall precautions. The nurse teaches the patient and family about fall precautions. Which action will the nurse take in accordance with hospital policy?

• A. Encourage visitors during visiting hours.
• B. Keep the patient on fall precautions until discharge.
• C. Check on the patient every shift.
• D. Raise all four side rails.

Correct answer: B

Rationale: The correct answer is B because patients on fall precautions need continuous monitoring until discharge to prevent falls. While encouraging visitors during visiting hours (Choice A) is important for the patient's well-being, it is not related to fall precautions. Checking on the patient every shift (Choice C) is an essential nursing intervention, but keeping the patient on fall precautions is more specific to preventing falls. Raising all four side rails (Choice D) is not recommended as it can restrict the patient's mobility and is considered a restraint practice.

2. A client has a prescription for vancomycin 1g IV intermittent infusion over 30 minutes every 12 hours. What action should the nurse take?

• A. Start the infusion immediately
• B. Slow down the infusion rate
• C. Contact the provider for prescription clarification
• D. Check blood pressure during the infusion

Correct answer: C

Rationale: The correct action for the nurse to take is to contact the provider for prescription clarification. Administering vancomycin over less than 60 minutes can lead to infusion reactions like hypotension and flushing. Starting the infusion immediately (choice A) is incorrect as it goes against the prescribed rate. Slowing down the infusion rate (choice B) without provider approval can result in underdosing the medication. Checking blood pressure during the infusion (choice D) is important but not the most immediate action needed in this situation.

3. A client is experiencing chest pain. Which action should the nurse take first?

• A. Administer aspirin
• B. Provide oxygen
• C. Perform an ECG
• D. Administer nitroglycerin

Correct answer: D

Rationale: Administering nitroglycerin is the priority action when a client is experiencing chest pain as it helps alleviate the pain caused by reduced blood flow to the heart. Oxygen can be beneficial, but nitroglycerin takes precedence in this situation. Aspirin can also be given, but nitroglycerin is the priority. Performing an ECG can provide valuable information but is not the first action to take in this scenario.

4. Which action by the nurse will help prevent ventilator-associated pneumonia (VAP) in a patient on mechanical ventilation?

• A. Provide oral care every 4 hours.
• B. Reposition the patient every 2 hours.
• C. Suction the patient as needed.
• D. Administer antibiotics as prescribed.

Correct answer: A

Rationale: The correct answer is A. Providing oral care every 4 hours helps prevent ventilator-associated pneumonia by reducing the buildup of bacteria in the mouth that can be aspirated into the lungs. Repositioning the patient every 2 hours is important for preventing pressure ulcers but is not directly related to preventing VAP. Suctioning the patient as needed is essential for maintaining airway patency but does not specifically prevent VAP. Administering antibiotics as prescribed is a treatment for infections but does not prevent VAP.

5. Which of the following best describes a somatic symptom disorder?

• A. Client experiences sudden onset of symptoms due to stress
• B. Physical manifestations occur due to underlying medical conditions
• C. Client has excessive preoccupation with physical symptoms without a medical cause
• D. Client avoids medical care due to fear of receiving a diagnosis

Correct answer: C

Rationale: The correct answer is C. Somatic symptom disorder is characterized by individuals having excessive preoccupation with physical symptoms that may or may not have an identifiable medical cause. Choice A is incorrect because the sudden onset of symptoms due to stress is more indicative of acute stress reaction. Choice B is incorrect as it describes physical manifestations related to known medical conditions, not somatic symptom disorder. Choice D is incorrect as it relates to health anxiety or illness anxiety disorder, where individuals avoid seeking medical care due to fear of receiving a diagnosis.

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