Nursing Elites

1. A patient refused a newly open fentanyl patch. Which of the following actions should the nurse take?

• A. Ask another nurse to witness the disposal of the new patch
• B. Dispose of the patch in a sharps container
• C. Send the patch back to the pharmacy
• D. Document the refusal and remove the patch

Correct answer: A

Rationale: The correct action for the nurse to take when a patient refuses a newly open fentanyl patch is to ask another nurse to witness the disposal of the new patch. This is essential for accountability and ensuring proper disposal procedures are followed. Choice B is incorrect because disposing of the patch in a sharps container without a witness does not ensure proper accountability. Choice C is incorrect as sending the patch back to the pharmacy is not the appropriate action for disposal. Choice D is incorrect because although documenting the refusal is important, it is also crucial to ensure proper disposal of the unused patch by having another nurse witness it.

2. How should signs of dehydration in an elderly patient be assessed?

• A. Monitor skin turgor
• B. Check for dry mucous membranes
• C. Monitor for sunken eyes
• D. Check capillary refill

Correct answer: A

Rationale: Corrected Rationale: Monitoring skin turgor is a reliable method to assess dehydration in elderly patients. Skin turgor refers to the skin's elasticity or the skin's ability to return to its normal position after being pinched. In dehydration, the skin loses its elasticity, becoming less flexible and slower to return to its original state. Checking for dry mucous membranes (Choice B), monitoring for sunken eyes (Choice C), and checking capillary refill (Choice D) are all relevant assessments in dehydration but are not as specific or sensitive as monitoring skin turgor. Dry mucous membranes and sunken eyes are indicators of dehydration, while capillary refill is more related to circulatory status and less specific to dehydration.

3. What is the best intervention for a patient experiencing respiratory distress?

• A. Administer oxygen
• B. Administer bronchodilators
• C. Administer IV fluids
• D. Provide humidified air

Correct answer: A

Rationale: Administering oxygen is the best intervention for a patient experiencing respiratory distress because it helps improve oxygenation and alleviate respiratory distress. Oxygen therapy is a critical and priority intervention in such cases as it aims to increase oxygen levels in the blood. Administering bronchodilators may be beneficial for specific respiratory conditions like asthma or COPD, but oxygen should be the initial priority. Administering IV fluids and providing humidified air, while important in certain situations, are not the primary interventions for respiratory distress.

4. A client is postoperative following cataract surgery. Which of the following instructions should the nurse include?

• A. Avoid lying flat for 24 hours after surgery.
• B. Avoid bending at the waist.
• C. Wear an eye patch at night for 1 week.
• D. Sleep on your affected side to reduce discomfort.

Correct answer: B

Rationale: The correct instruction that the nurse should include for a client postoperative following cataract surgery is to avoid bending at the waist. Bending at the waist can increase intraocular pressure, which is not recommended after cataract surgery. Choices A, C, and D are incorrect because lying flat for 24 hours after surgery may not be necessary, wearing an eye patch at night for a week is not a standard postoperative instruction for cataract surgery, and sleeping on the affected side may not necessarily reduce discomfort and can increase pressure on the eye.

5. A client who has a positive stool culture for Clostridium difficile should be placed in which type of room for infection control purposes?

• A. Wear a face shield prior to entering the room.
• B. Place the client in a private room.
• C. Place the client in a negative pressure room.
• D. Use an alcohol-based hand rub following client care.

Correct answer: B

Rationale: Placing the client in a private room is the appropriate infection control measure for C. difficile to prevent the spread of infection. While wearing a face shield may be necessary for procedures that generate splashes or sprays, it is not the primary precaution for C. difficile. Negative pressure rooms are typically used for airborne infections, not for C. difficile. Using an alcohol-based hand rub is important for hand hygiene but is not specific to managing C. difficile infection.

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