Nursing Elites

1. What is the appropriate intervention for a patient experiencing hypovolemic shock?

• A. Administer IV fluids
• B. Monitor blood pressure
• C. Place the patient in Trendelenburg position
• D. Administer oxygen

Correct answer: A

Rationale: The correct intervention for a patient experiencing hypovolemic shock is to administer IV fluids. In hypovolemic shock, there is a significant loss of circulating blood volume leading to inadequate perfusion to tissues. Administering IV fluids is crucial to restore blood volume and improve tissue perfusion. Monitoring blood pressure (choice B) is important but not the primary intervention in hypovolemic shock. Placing the patient in Trendelenburg position (choice C) can worsen outcomes by increasing intracranial pressure and is no longer recommended. Administering oxygen (choice D) is beneficial for many conditions but does not address the underlying issue of inadequate circulating blood volume in hypovolemic shock.

2. A charge nurse on a medical-surgical unit is planning assignments for a licensed practical nurse (LPN) who has been sent from the postpartum unit due to a staffing shortage for the shift. Which of the following client assignments should the nurse delegate to the LPN?

• A. A client who is postoperative following a bowel resection with an NGT set to continuous suction.
• B. A client who has fractured a femur yesterday and is experiencing shortness of breath.
• C. A client who sustained a concussion and has unequal pupils.
• D. A client who has an Hgb of 6.3 g/dl and a prescription for packed RBCs.

Correct answer: A

Rationale: The correct answer is A because the LPN can care for stable clients with complex needs, such as managing an NGT set to continuous suction. Choices B, C, and D involve clients with more acute conditions that require a higher level of assessment and intervention, making them unsuitable for delegation to an LPN. Choice B requires prompt evaluation of the shortness of breath in a client with a recent femur fracture, which is beyond the LPN's scope. Choice C involves a head injury and unequal pupils, indicating the need for neurological assessment and close monitoring. Choice D relates to a critically low hemoglobin level and the need for blood transfusion, requiring careful monitoring and potential intervention beyond the LPN's role.

3. Which of the following is an early indicator that a client with a tracheostomy may require suctioning?

• A. Decreased respiratory rate
• B. Irritability
• C. Bradycardia
• D. Decreased oxygen saturation

Correct answer: B

Rationale: Irritability is an early indicator that suctioning is necessary for a client with a tracheostomy. Irritability can signal discomfort or difficulty breathing, which may be due to the need for suctioning to clear the airway. Decreased respiratory rate, bradycardia, and decreased oxygen saturation are not typically early indicators that suctioning is needed in a client with a tracheostomy. These symptoms may occur later if the airway is not cleared promptly.

4. What is the correct procedure for taking a telephone order from a provider?

• A. State patient name, drug, dose, route, frequency, and read back the order
• B. State the medication and ask for a witness to listen to the order
• C. Write down the order and verify with the provider within 12 hours
• D. Have the provider verify the order during the next in-person visit

Correct answer: A

Rationale: The correct procedure for taking a telephone order from a provider is to state the patient's name, drug, dose, route, frequency, and then read back the order to ensure accuracy. This process helps in preventing errors and ensures that all relevant information is correctly documented. Choice B is incorrect because having a witness listen to the order is not a standard practice and may not guarantee accuracy. Choice C is incorrect as verifying the order within 12 hours may lead to delays in patient care. Choice D is incorrect because waiting for the provider to verify the order during the next in-person visit could result in a significant delay in administering necessary medication.

5. A nurse is providing discharge instructions to a client with home oxygen therapy. What safety measure should the nurse emphasize?

• A. Allow smoking in designated outdoor areas
• B. Keep oxygen tanks upright and away from heat sources
• C. Store oxygen tanks in a closet when not in use
• D. Keep oxygen equipment at least 10 feet away from open flames

Correct answer: B

Rationale: The correct safety measure that the nurse should emphasize is to keep oxygen tanks upright and away from heat sources. This is crucial to prevent the risk of fire or explosion. Choice A is incorrect as smoking near oxygen can lead to a fire hazard. Choice C is also incorrect as storing oxygen tanks in enclosed spaces can be dangerous. Choice D, although related to safety, does not address the immediate risk of keeping oxygen tanks away from heat sources.

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