Nursing Elites

1. Twenty minutes after beginning a heat application, the client states that the heating pad no longer feels warm enough. What is the best response by the nurse?

• A. That means you have derived the maximum benefit, and the heat can be removed.
• B. Your blood vessels are becoming dilated and removing the heat from the site.
• C. We will increase the temperature by 5 degrees when the pad no longer feels warm.
• D. The body's receptors adapt over time as they are exposed to heat.

Correct answer: D

Rationale: Choice (D) describes thermal adaptation, which occurs 20 to 30 minutes after heat application. The body's receptors adjust to the constant heat exposure, leading to a decreased sensation of warmth. Choices (A) and (B) provide inaccurate information regarding the situation, while choice (C) is not physiologically sound and could potentially harm the client by increasing the temperature unnecessarily.

2. The nurse determines that a postoperative client's respiratory rate has increased from 18 to 24 breaths/min. Based on this assessment finding, which intervention is most important for the nurse to implement?

• A. Encourage the client to increase ambulation in the room.
• B. Offer the client a high-carbohydrate snack for energy.
• C. Force fluids to thin the client's pulmonary secretions.
• D. Determine if pain is causing the client's tachypnea.

Correct answer: D

Rationale: An increased respiratory rate can be a sign of various issues postoperatively, including pain. Assessing and managing pain is crucial as it can lead to tachypnea. Pain, anxiety, and fluid accumulation in the lungs can all contribute to an increased respiratory rate. Therefore, determining if pain is causing the tachypnea is the most important intervention to address the underlying cause. Encouraging ambulation, offering snacks, or forcing fluids are not the priority in this situation as pain assessment takes precedence in managing the increased respiratory rate.

3. A client is in the radiology department at 0900 when the prescription for levofloxacin (Levaquin) 500 mg IV q24h is scheduled to be administered. The client returns to the unit at 1300. What is the best intervention for the nurse to implement?

• A. Contact the healthcare provider and complete a medication variance form.
• B. Administer the Levaquin at 1300 and resume the 0900 schedule the next day.
• C. Notify the charge nurse and complete an incident report to explain the missed dose.
• D. Give the missed dose at 1300 and change the schedule to administer daily at 1300.

Correct answer: D

Rationale: To maintain a therapeutic level of medication, the nurse should administer the missed dose as soon as possible and adjust the administration schedule to prevent dangerously high levels of the drug in the bloodstream (D). It is important to document the reason for the delayed dose. Contacting the healthcare provider and completing a medication variance form (A) may cause unnecessary delays. Notifying the charge nurse and completing an incident report (C) should be done after addressing the immediate medication administration issue. Administering the medication at 1300 and resuming the 0900 schedule the next day (B) could lead to suboptimal therapeutic levels and potential complications.

4. What intervention should the healthcare provider include in the plan of care for a client receiving treatment with an Unna's paste boot for leg ulcers due to chronic venous insufficiency?

• A. Check capillary refill of toes on the lower extremity with the Unna's paste boot.
• B. Apply dressing to the wound area before applying the Unna's paste boot.
• C. Wrap the leg from the knee down towards the foot.
• D. Remove the Unna's paste boot every 8 hours to assess wound healing.

Correct answer: A

Rationale: When an Unna's paste boot is applied for leg ulcers due to chronic venous insufficiency, it is crucial to check the capillary refill of the toes on the lower extremity to ensure adequate circulation. The Unna's paste boot can become rigid after drying, potentially affecting circulation distally. Monitoring capillary refill helps assess the perfusion status of the distal extremity and ensures that the treatment is not compromising circulation to the toes.

5. At a motor vehicle collision site, a nurse applies pressure to a groin wound that is bleeding profusely until emergency personnel arrive. Subsequently, the client undergoes leg amputation and sues the nurse for malpractice. What is the most likely outcome of this lawsuit?

• A. The Patient's Bill of Rights protects clients from malicious intents, so the nurse could lose the case.
• B. The lawsuit may be settled out of court, but the nurse's license is unlikely to be revoked.
• C. There will be no judgment against the nurse, as their actions were protected under the Good Samaritan Act.
• D. The client will win because the four elements of negligence (duty, breach, causation, and damages) cannot be proved.

Correct answer: C

Rationale: The Good Samaritan Act shields healthcare professionals who act in good faith and offer reasonable care from malpractice claims, irrespective of the client's outcome. In this scenario, the nurse stopping to render aid at the accident scene and applying pressure to the bleeding groin wound would likely be covered by the Good Samaritan Act, protecting the nurse from legal repercussions related to the subsequent leg amputation.

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