Nursing Elites

1. The healthcare professional prepares to administer buccal medication. The medicine should be placed...

• A. On the client's skin
• B. Between the client's cheeks and gums
• C. Under the client's tongue
• D. On the client's conjunctiva

Correct answer: B

Rationale: Buccal medication is administered by placing it between the client's cheeks and gums. This route allows for the medication to be absorbed through the mucous membranes in the mouth, providing a rapid onset of action compared to oral ingestion. Placing the medication under the tongue (sublingual) allows for absorption through the sublingual mucosa, not the buccal mucosa. Placing medication on the skin or the conjunctiva is not appropriate for buccal administration.

2. When is sterile technique used?

• A. During strict isolation procedures
• B. After terminal disinfection is performed
• C. For invasive procedures
• D. When protective isolation is necessary

Correct answer: C

Rationale: Sterile technique is utilized during invasive procedures to prevent the introduction of pathogens, minimizing the risk of infections. This strict approach ensures that the procedure is performed in a sterile environment, reducing the chances of contamination and subsequent complications.

3. The physician orders a maintenance dose of 5,000 units of subcutaneous heparin (an anticoagulant) daily. Nursing responsibilities for Mrs. Mitchell now include:

• A. Reviewing daily activated partial thromboplastin time (APTT) and prothrombin time.
• B. Reporting an APTT above 45 seconds to the physician
• C. Assessing the patient for signs and symptoms of frank and occult bleeding
• D. All of the above

Correct answer: D

Rationale: The correct answer is D. When a physician orders a maintenance dose of subcutaneous heparin, nursing responsibilities include reviewing daily activated partial thromboplastin time (APTT) and prothrombin time to monitor the patient's coagulation status, reporting an APTT above 45 seconds to the physician as it may indicate a risk of bleeding, and assessing the patient for signs and symptoms of frank and occult bleeding, which are potential adverse effects of anticoagulant therapy. Therefore, all the options listed are essential nursing responsibilities when a patient is on subcutaneous heparin therapy.

4. When a chest tube is accidentally removed from a client, which of the following actions should the nurse NOT take first?

• A. Obtain a chest x-ray
• B. Apply sterile gauze to the insertion site
• C. Place tape around the insertion site
• D. Assess respiratory status

Correct answer: B

Rationale: When a chest tube is accidentally removed, the priority action for the nurse is to immediately seal the insertion site with a gloved hand, a sterile occlusive dressing, or petroleum gauze to prevent air from entering the pleural space and causing a pneumothorax. Applying sterile gauze to the insertion site is not the correct initial action. The first step is to prevent respiratory compromise by ensuring the site is sealed. Therefore, the nurse should not apply sterile gauze to the insertion site first.

5. Prior to a thoracentesis, which of the following actions should the nurse take?

• A. Position the client in an upright position, leaning over the bedside table.
• B. Explain the procedure.
• C. Obtain ABGs.
• D. Administer benzocaine spray.

Correct answer: A

Rationale: Positioning the client in an upright position, leaning over the bedside table helps to facilitate access to the thoracic cavity during the thoracentesis procedure. This position allows for easier identification and access to the insertion site. Explaining the procedure to the client is important, but positioning is the priority. Obtaining ABGs is not directly related to the thoracentesis procedure. Administering benzocaine spray is not a standard practice before a thoracentesis.

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