Nursing Elites

1. When responding to a call light and finding a client on the bathroom floor, what should the nurse do FIRST?

• A. Check the client for injuries
• B. Call for additional help
• C. Move the client to a sitting position
• D. Assist the client back to bed

Correct answer: A

Rationale: Checking the client for injuries is the priority when finding them on the bathroom floor. This action ensures the client's safety as it allows for immediate assessment of any potential harm. Calling for help may be necessary, but assessing for injuries takes precedence to address any immediate threats to the client's well-being. Moving the client to a sitting position or assisting them back to bed should only be done after ensuring there are no serious injuries requiring prompt medical attention. Therefore, the correct first action is to check the client for injuries.

2. When reviewing EBP about the administration of O2 therapy, what is the recommended maximum flow rate for regulating O2 via nasal cannula?

• A. Regulate O2 via nasal cannula no more than 6L
• B. Regulate O2 via nasal cannula no more than 2L
• C. Regulate O2 via nasal cannula no more than 4L
• D. Regulate O2 via nasal cannula no more than 8L

Correct answer: A

Rationale: The correct answer is to regulate O2 via nasal cannula no more than 6L. This flow rate is generally recommended to ensure adequate oxygen delivery without causing discomfort or potential harm to the patient. Choices B, C, and D are incorrect as they suggest flow rates that are either too low (2L, 4L) or too high (8L). A flow rate of 2L might not provide sufficient oxygen, while 4L could be inadequate for some patients. On the other hand, a flow rate of 8L could be excessive and potentially harmful, leading to complications like oxygen toxicity. Therefore, the optimal recommendation is to regulate O2 via nasal cannula at a maximum of 6L to balance effectiveness and safety.

3. When caring for a client at the end of life, which statement by the client’s partner reflects effective coping?

• A. I am relying on support from our family during this time.
• B. I am feeling overwhelmed but don’t want to talk about it.
• C. I am managing everything on my own without help.
• D. I prefer to stay alone with my partner.

Correct answer: A

Rationale: The correct answer is A: 'I am relying on support from our family during this time.' When a client is at the end of life, relying on support from family can be an effective coping mechanism. It allows the partner to share the emotional burden, seek comfort, and prevent feelings of isolation. Choice B reflects a reluctance to express feelings, which can hinder coping mechanisms by internalizing stress. Choice C suggests handling everything alone, which can lead to burnout and emotional strain due to the overwhelming responsibilities. Choice D, preferring to stay alone with the partner, may limit access to external support that could provide additional emotional and practical assistance during this challenging time, making it a less effective coping strategy.

4. A nurse offers pain medication to a client who is postoperative before ambulation. The nurse understands that this aspect of care delivery is an example of which of the following ethical principles?

• A. Fidelity
• B. Autonomy
• C. Justice
• D. Beneficence

Correct answer: D

Rationale: The correct answer is D: Beneficence. Beneficence involves actions intended to benefit the client, such as providing pain relief. In this scenario, the nurse is demonstrating beneficence by offering pain medication to alleviate the client's discomfort and promote their well-being. Fidelity (A) relates to being faithful to agreements and commitments, autonomy (B) refers to respecting a client's right to make decisions about their care, and justice (C) involves fairness and equal treatment. While these ethical principles are important in healthcare, the situation described primarily exemplifies the principle of beneficence.

5. When preparing an injection for opioid medication, a nurse draws 1mL from a 2mL vial. What should the nurse do next?

• A. Ask another nurse to observe medication wastage
• B. Document the amount of medication drawn on the MAR
• C. Dispose of the remaining medication in a sharps container
• D. Administer the entire vial of medication to avoid wastage

Correct answer: A

Rationale: When drawing medication from a vial, especially for controlled substances like opioids, any wastage must be witnessed by another healthcare professional to ensure accuracy, prevent diversion, and maintain safety standards. This process is crucial for proper documentation and accountability. Recording the amount drawn on the Medication Administration Record (MAR) is important for tracking administered doses and preventing errors. Disposing of the remaining medication in a sharps container is not recommended as it does not address proper wastage documentation. Administering the entire vial of medication just to avoid wastage is inappropriate and can lead to potential harm or overdose in the patient.

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