Nursing Elites

1. Based on the computer documentation in the EMR, which action should the PN implement?

• A. Give the rubella vaccine subcutaneously
• B. Observe the mother breastfeeding her infant
• C. Call the nursery for the infant's blood type results
• D. Administer hydrocodone/acetaminophen one tablet for pain

Correct answer: A

Rationale: The rubella vaccine is crucial for preventing rubella infection, which can cause severe congenital disabilities if contracted during pregnancy. Administering the vaccine subcutaneously is the correct action based on EMR documentation. Observing breastfeeding, calling the nursery for blood type results, and administering pain medication are not indicated by the EMR documentation and are not relevant to the situation described in the question.

2. There has been a serious explosion at a local factory, and many of the injured are arriving at the hospital. Which of the following patients should a nurse attend to first?

• A. A 30-year-old male who is able to walk into the hospital on his own but has numerous lacerations on the chest and face
• B. A 45-year-old male who was brought in on a stretcher, has been assessed as having respiration and circulation within normal limits, and can follow simple commands
• C. A 50-year-old woman who can walk but has a broken arm and numerous lacerations
• D. A 19-year-old man who has numerous lacerations all over the body and whose respiration exceeds 30 breaths per minute

Correct answer: D

Rationale: The correct answer is D. The 19-year-old man with a respiration rate exceeding 30 breaths per minute is showing signs of respiratory distress, indicating a potentially life-threatening condition that requires immediate attention. Patients with respiratory distress should be prioritized as it is a critical condition. Choices A, B, and C describe patients with injuries that are less immediately life-threatening or who are more stable based on the provided information, so they can be attended to after the patient with respiratory distress. Therefore, the nurse should attend to the 19-year-old man first to address his respiratory distress and ensure his condition does not deteriorate further.

3. What is the primary cause of diabetic ketoacidosis (DKA)?

• A. Insulin deficiency
• B. Overhydration
• C. Excess carbohydrate intake
• D. Excess insulin

Correct answer: A

Rationale: The correct answer is A: Insulin deficiency. Diabetic ketoacidosis occurs due to a severe lack of insulin, causing the body to break down fat for energy, leading to the production of ketones and acidification of the blood. Option B, Overhydration, is incorrect as DKA is characterized by dehydration rather than overhydration. Option C, Excess carbohydrate intake, is incorrect because while high blood sugar levels can contribute to DKA, the primary cause is insulin deficiency. Option D, Excess insulin, is also incorrect as DKA is not caused by an excess of insulin but rather by a lack of it.

4. While caring for a client with an AV fistula in the left forearm, the nurse observed a palpable buzzing sensation over the fistula. What action should the nurse take?

• A. Loosen the dressing of the fistula
• B. Report the presence of a bounding pulse
• C. Document that the fistula is intact
• D. Apply gentle pressure over the site

Correct answer: C

Rationale: The correct answer is C: Document that the fistula is intact. The palpable buzzing sensation (known as a thrill) over the AV fistula indicates proper functioning. It is essential for the nurse to document this finding to ensure ongoing monitoring of the fistula's status. Choices A, B, and D are incorrect. Choice A is incorrect because there is no indication to loosen the dressing. Choice B is incorrect as a bounding pulse is not associated with the palpable buzzing sensation of a thrill. Choice D is incorrect as applying pressure over the site is not necessary for this situation.

5. Which task could the PN safely delegate to the UAP?

• A. Oral feeding of a two-year-old child after application of a hip spica cast
• B. Assessment of the placement and patency of a NG tube
• C. Participation in staff rounds to record notes regarding client goals
• D. Evaluation of a client's incisional pain following narcotic administration

Correct answer: A

Rationale: The correct answer is A because oral feeding of a child is a task that can be safely delegated to an unlicensed assistive personnel (UAP). This task involves providing basic care and does not require specialized nursing skills. Choices B, C, and D involve assessments, recording client goals, and evaluating pain, respectively, which all require specialized nursing knowledge, judgment, and skills. These tasks are not within the scope of practice for a UAP.

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