Nursing Elites

1. An RN is writing reminders for good documentation for the nurses on her staff. The purpose is to ensure nursing documentation is legally credible. Which of the following is a recommendation she should include in the reminders?

• A. Use shortcuts in documentation.
• B. Only use approved abbreviations.
• C. Documentation should be subjective.
• D. Document after care is provided.

Correct answer: B

Rationale: The correct recommendation the RN should include in the reminders is to 'Only use approved abbreviations.' Using shortcuts in documentation (choice A) may lead to errors or omissions, affecting the credibility of documentation. Documentation should be objective (choice C) rather than subjective to ensure accuracy and legal credibility. It is essential to document care promptly after providing it (choice D) to maintain the accuracy and completeness of patient records, but using approved abbreviations is a more specific recommendation to enhance legal credibility.

2. When using an open irrigation technique to irrigate a client's indwelling urinary catheter, which of the following actions should the nurse take?

• A. Position the client in a side-lying position.
• B. Perform the irrigation using a 20-mL syringe.
• C. Instill 15 mL of irrigation fluid into the catheter with each flush.
• D. Measure and record the amount of irrigant used.

Correct answer: B

Rationale: When irrigating an indwelling urinary catheter, the nurse should use a 20-mL syringe for the procedure. This syringe size helps to provide adequate pressure for effective irrigation. Placing the client in a side-lying position is not necessary for this procedure. Instilling a specific amount of irrigation fluid into the catheter is not mentioned in the scenario. Subtracting the amount of irrigant used from the client's urine output is not a standard practice in catheter irrigation.

3. Which information will the nurse include when teaching a 50-year-old patient who has type 2 diabetes about glyburide (Micronase, DiaBeta, Glynase)?

• A. Glyburide decreases glucagon secretion from the pancreas.
• B. Glyburide stimulates insulin production and release from the pancreas.
• C. Glyburide should be taken even if the morning blood glucose level is low.
• D. Glyburide should not be used for 48 hours after receiving IV contrast media.

Correct answer: B

Rationale: The correct answer is B: Glyburide stimulates insulin production and release from the pancreas. Glyburide belongs to the sulfonylurea class of antidiabetic medications, which work by stimulating the pancreas to produce and release more insulin. This helps to lower blood glucose levels. Choice A is incorrect because glyburide does not decrease glucagon secretion; instead, it acts on insulin. Choice C is incorrect because taking glyburide when blood glucose is low can lead to hypoglycemia. Choice D is incorrect as there is no specific interaction between glyburide and IV contrast media that requires avoiding its use for 48 hours.

4. A nurse is caring for a client who has diarrhea due to shigella. Which of the following precautions should the nurse implement for this client?

• A. Have the client wear a mask when receiving visitors.
• B. Limit the client's time with visitors to no more than 30 minutes per day.
• C. Assign the client to a room with negative-pressure airflow exchange.
• D. Wear a gown when caring for the client.

Correct answer: B

Rationale: The correct answer is B because limiting the client's time with visitors helps prevent the spread of shigella infection to others. Shigella is transmitted through the fecal-oral route, so minimizing contact time reduces the risk of transmission. Choice A is incorrect as there is no need for the client to wear a mask in this situation. Choice C is also incorrect as negative-pressure airflow exchange rooms are typically used for clients with airborne infections. Choice D is incorrect as wearing a gown is not the primary precaution needed for shigella infection.

5. A nurse is assessing a client's readiness to learn about insulin self-administration. Which of the following statements should the nurse identify as an indication that the client is ready to learn?

• A. "I can concentrate best in the morning."
• B. "It is difficult to read the instructions because my glasses are at home."
• C. "I'm wondering why I need to learn this."
• D. "You will have to talk to my partner about this."

Correct answer: D

Rationale: The correct answer is D, "You will have to talk to my partner about this." This response indicates that the client is willing to involve their partner in the learning process, showing readiness to take responsibility and engage in the education. Choices A, B, and C demonstrate potential barriers to learning: A indicates a preference for learning time but does not show active involvement, B focuses on external factors hindering learning, and C reflects a lack of understanding or motivation for the learning.

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