Nursing Elites

1. 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.

2. If a healthcare provider administers an injection to a patient who refuses, they have committed:

• A. Assault and battery
• B. Negligence
• C. Malpractice
• D. None of the above

Correct answer: A

Rationale: When a healthcare provider administers treatment, such as an injection, against a patient's refusal or will, it constitutes assault and battery. Assault refers to the intentional act that causes a person to fear that they will be touched without consent, while battery involves the actual harmful or offensive contact. In this scenario, administering the injection without the patient's consent is both an assault (causing fear of unwanted contact) and a battery (unwanted physical contact). Therefore, the correct answer is 'Assault and battery.' Negligence refers to a failure to exercise the appropriate level of care expected in a situation, while malpractice involves professional negligence or misconduct.

3. A healthcare professional realizes that the wrong medication has been administered to a client. Which of the following actions should the healthcare professional take first?

• A. Notify the provider.
• B. Report the incident to the healthcare facility's manager.
• C. Monitor vital signs.
• D. Fill out an incident report.

Correct answer: C

Rationale: In a situation where the wrong medication has been administered to a client, the immediate priority is to assess and monitor the client's vital signs to identify any adverse effects of the incorrect medication. This action takes precedence over notifying the provider, reporting the incident, or filling out an incident report. Monitoring vital signs allows for timely recognition and intervention if the client experiences any negative reactions to the wrong medication, ensuring their safety and well-being.

4. Which of the following techniques involves the sense of sight?

• A. Inspection
• B. Palpation
• C. Percussion
• D. Auscultation

Correct answer: A

Rationale: The correct answer is Inspection (Choice A). Inspection is a technique that involves observing the patient using the sense of sight. During inspection, a healthcare provider visually examines the patient for any abnormalities, changes, or specific signs that may help in diagnosing a condition. Palpation (Choice B) involves using the sense of touch to feel for abnormalities. Percussion (Choice C) involves tapping the body to produce sounds that can help identify the underlying structures. Auscultation (Choice D) involves listening to sounds produced by the body, typically using a stethoscope. Therefore, in this context, the technique that specifically involves the sense of sight is Inspection.

5. During a client's first hospitalization, which of the following actions ensures the safety of the client?

• A. Keep unnecessary furniture out of the way
• B. Keep the lights on at all times
• C. Keep side rails up at all times
• D. Keep all equipment out of view

Correct answer: A

Rationale: During a client's first hospitalization, it is essential to keep unnecessary furniture out of the way to prevent obstacles and ensure a safe environment. This action helps reduce the risk of accidents or falls, promoting the client's safety and well-being. Keeping the lights on at all times may not be necessary and can disrupt the client's rest. Keeping side rails up at all times can restrict the client's movement and independence unnecessarily. Keeping all equipment out of view may hinder the healthcare team's ability to monitor and access necessary tools for providing care.

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