Nursing Elites

1. The healthcare provider who is preparing to give an adolescent client a prescribed antipsychotic medication notes that parental consent has not been obtained. Which action should the provider take?

• A. Review the chart for a signed consent for medication administration.
• B. Obtain parental consent before giving the medication.
• C. Do not give the medication and document the reason.
• D. Complete an incident report and notify the adolescent.

Correct answer: C

Rationale: The correct action is for the provider not to administer the medication and to document the reason. In the case of a minor, parental consent is required for medical treatment, including medication administration. It is important to follow legal and ethical guidelines to ensure the adolescent's well-being and rights are protected. Choice A is incorrect because simply reviewing the chart does not address the lack of parental consent. Choice B is incorrect as obtaining parental consent should be done before medication administration. Choice D is incorrect as notifying the adolescent is not the appropriate action in this situation, as parental consent is legally required for a minor's medical treatment.

2. When a student nurse is caught taking a copy of a client's medication administration record to help a friend prepare for the next day's clinical, what should the nurse respond first?

• A. Ask the nursing supervisor to meet with the student.
• B. Notify the student's clinical instructor of the situation.
• C. Ask the student if permission was obtained from the client.
• D. Explain that the records are hospital property and may not be removed.

Correct answer: D

Rationale: The correct response when a student nurse is caught taking a copy of a client's medication administration record is to explain that the records are hospital property and cannot be removed. It is essential to educate the student about the confidentiality and security of patient information, emphasizing that even with the client's consent, such actions are unacceptable. Option A is not the immediate action needed, as addressing the student directly should come first. Option B involves notifying another party before addressing the student directly. Option C is incorrect because even if the client gave permission, patient records are confidential and cannot be shared without authorization.

3. The nurse finds a client crying behind a locked bathroom door. The client will not open the door. Which action should the nurse implement first?

• A. Instruct an unlicensed assistive personnel (UAP) to stay and keep talking to the client.
• B. Sit quietly in the client's room until the client leaves the bathroom.
• C. Allow the client to cry alone and leave the client in the bathroom.
• D. Talk to the client and attempt to find out why the client is crying.

Correct answer: D

Rationale: When encountering a client in distress, the nurse's initial response should be to communicate with the client to assess the situation and provide support. By talking to the client and attempting to find out the reason for their distress, the nurse can offer appropriate assistance and ensure the client's well-being. This action prioritizes the client's emotional needs and helps establish a therapeutic relationship, which is essential in nursing care.

4. When culturing a wound, the nurse should obtain the sample from which part of the wound?

• A. The outer edges of the wound.
• B. All necrotic sections of the wound.
• C. Areas containing purulent or pooled exudates.
• D. Any particularly painful area of the wound.

Correct answer: C

Rationale: To collect a wound culture, the nurse should first clean the wound to remove skin flora and then insert a sterile swab from a culturette tube into the wound secretions.

5. A client is admitted with a diagnosis of fluid volume excess. Which intervention should the nurse include in the client's plan of care?

• A. Encourage increased fluid intake.
• B. Place the client in a high Fowler's position.
• C. Measure the client's intake and output.
• D. Restrict dietary sodium intake.

Correct answer: D

Rationale: Restricting dietary sodium intake (D) is the most critical intervention for a client with fluid volume excess to prevent further fluid retention. Encouraging increased fluid intake (A) would exacerbate the issue by adding more fluid to the body. Placing the client in a high Fowler's position (B) is more relevant for respiratory issues than fluid volume excess. While measuring intake and output (C) is important for assessing fluid balance, restricting sodium intake is the priority as it helps manage fluid levels more effectively by reducing fluid retention.

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