Nursing Elites

1. A primigravida begins labor when her family is unavailable and she is alone. She is very upset that her family is not with her. Which approach can the nurse take to meet the client's needs at this time?

• A. asking whether another individual wants to be her support person
• B. assuring her that a nursing staff member will be with her at all times
• C. telling her you will try to locate her family
• D. reinforcing the woman's confidence in her own abilities to cope and maintain a sense of control

Correct answer: A

Rationale: In this situation, the best approach for the nurse is to ask whether another individual wants to be the client's support person. This empowers the client to choose someone to be with her until her family can join her, providing the needed support and comfort. Assuring her that a nursing staff member will be with her at all times (Choice B) may not fully address her emotional needs for familiar support. Telling her you will try to locate her family (Choice C) may not be feasible in the immediate situation and may not provide immediate emotional support. While reinforcing the woman's confidence in her own abilities (Choice D) is important, it may not fully address her current need for emotional support and presence of a companion.

2. A nurse calls a health care provider to report that a client with congestive heart failure (CHF) is exhibiting dyspnea and worsening of wheezing. The health care provider, who is in a hurry because of a situation in the emergency department, gives the nurse a telephone prescription for furosemide (Lasix) but does not specify the route of administration. What is the appropriate action on the part of the nurse?

• A. Calling the health care provider who gave the telephone prescription to clarify the prescription
• B. Administering the medication orally and clarifying the prescription once the health care provider has finished caring for the client in the emergency department
• C. Calling the nursing supervisor for assistance in determining the route of administration
• D. Administering the medication intravenously because this route is generally used for clients with CHF

Correct answer: A

Rationale: Telephone prescriptions involve a health care provider dictating a prescribed therapy over the telephone to the nurse. The nurse must clarify the prescription by repeating it clearly and precisely to the health care provider. The nurse then writes the prescription on the health care provider's prescription sheet or enters it into the electronic medical record. It is crucial not to interpret an unclear prescription or administer a medication by a route that has not been expressly prescribed. In this case, the nurse should call the health care provider who gave the telephone prescription to clarify the prescription, ensuring the correct route of administration is specified. Options B, C, and D are incorrect because administering the medication without clarification, seeking assistance from the nursing supervisor, or choosing an arbitrary route of administration can compromise patient safety and violate medication administration protocols.

3. Following a recent tattoo, someone should be screened for:

• A. tuberculosis.
• B. herpes.
• C. hepatitis.
• D. syphilis.

Correct answer: C

Rationale: Following a recent tattoo, someone should be screened for hepatitis. Tattooing puts a client at risk for blood-borne hepatitis B or C if strict sterile procedures are not followed. Tuberculosis is an airborne pathogen, while herpes and syphilis are spread through direct contact like sexual activity. Therefore, hepatitis is the most relevant infection to screen for after getting a tattoo.

4. Why is accurate documentation of assessment findings regarding pressure ulcers crucial?

• A. To comply with legal requirements for documenting lesions.
• B. To meet hospital policies for documenting lesions.
• C. To fulfill physician's documentation requirements for lesions.
• D. Because the nursing assessment of ulcers is a standard of nursing practice.

Correct answer: D

Rationale: Accurate documentation of assessment findings regarding pressure ulcers is crucial because the nursing assessment of ulcers is a standard practice in nursing care. Documenting these findings not only ensures continuity of care but also plays a vital role in preventing further progression of the ulcer. Choices A, B, and C are incorrect because while laws, hospital policies, and physician requirements may influence documentation practices, the primary reason for accurate documentation lies in the standards of nursing practice and the quality of patient care.

5. Ethics committees typically do not handle which of the following issues?

• A. Nonpayment of bills.
• B. Euthanasia.
• C. Starting or stopping treatment.
• D. Use of feeding tubes.

Correct answer: A

Rationale: Ethics committees primarily focus on addressing ethical dilemmas in healthcare. Issues like euthanasia, decisions regarding starting or stopping treatment, and the use of feeding tubes for nutritional support involve complex ethical considerations related to patient care and end-of-life decisions, which are commonly deliberated by ethics committees. However, nonpayment of bills is a financial matter and falls outside the typical scope of ethics committees' functions.

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