Nursing Elites

1. Why is monitoring Serum Vancomycin levels important?

• A. to assess renal function
• B. to determine therapeutic range
• C. to measure trough levels
• D. to evaluate antibiotic resistance

Correct answer: B

Rationale: Monitoring Serum Vancomycin levels is essential to determine the drug's therapeutic range, ensuring optimal effectiveness while avoiding toxicity. Peak levels indicate the drug's highest concentration, while trough levels represent the lowest concentration before the next dose. Assessing renal function is typically done using creatinine, BUN, or creatinine clearance tests, not Serum Vancomycin levels. Evaluating antibiotic resistance involves sensitivity testing, not monitoring Vancomycin levels. Therefore, the correct answer is to determine the therapeutic range.

2. While repositioning a comatose client, the nurse senses a tingling sensation as she lowers the bed. What action should she take?

• A. Unplug the bed's power source.
• B. Remove the client from the bed immediately.
• C. Notify the biomedical department at once.
• D. Turn off the oxygen.

Correct answer: A

Rationale: The correct action for the nurse to take when sensing a tingling sensation while lowering the bed with a comatose client is to unplug the bed's power source. This should be the initial step as there may be a fault in the bed's grounding. Removing the client from the bed immediately is not safe until the electrical issue is resolved. Notifying the biomedical department is important but should come after ensuring the immediate safety of the client. Turning off the oxygen is not necessary unless there is a specific issue related to oxygen delivery, which is not indicated in this scenario.

3. While preparing a client for a bronchoscopy, a nurse notes that the client is wearing a gold necklace. What should the nurse do to safeguard the client's necklace?

• A. Ask the client for permission to lock the necklace in the hospital safe
• B. Ask the client to remove the necklace and place it in the top drawer of the bedside table
• C. Ask the client whether the necklace is gold
• D. Ask the client to sign a release to free the hospital of responsibility if the necklace is damaged or lost during the procedure

Correct answer: A

Rationale: When a client has valuables such as jewelry, the nurse should ensure their safekeeping. It is appropriate for the nurse to ask the client for permission to lock the necklace in the hospital safe to prevent loss or damage. This option prioritizes the security of the necklace while allowing the client to make an informed decision. Asking the client to sign a release form does not guarantee the necklace's safety; it only releases the hospital from liability. Placing the necklace in a bedside table drawer does not provide adequate security as it is not as secure as a hospital safe. Inquiring whether the necklace is gold is irrelevant to safeguarding the jewelry during the procedure, as the primary concern is its safekeeping.

4. A client is complaining of difficulty walking secondary to a mass in the foot. The nurse should document this finding as:

• A. Plantar fasciitis.
• B. Hallux valgus.
• C. Hammertoe.
• D. Morton's neuroma.

Correct answer: D

Rationale: The correct answer is Morton's neuroma. Morton's neuroma is a small mass or tumor in a digital nerve of the foot, causing symptoms such as pain and difficulty walking. Hallux valgus is commonly known as a bunion and involves the deviation of the big toe towards the other toes. Hammertoe is a condition where one or more toes are bent in a claw-like position. Plantar fasciitis is characterized by pain and inflammation in the arch of the foot, not typically associated with a mass causing difficulty walking.

5. 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.

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