Nursing Elites

1. When assessing a client with wrist restraints, the nurse observes that the fingers on the right hand are blue. What action should the nurse implement first?

• A. Loosen the right wrist restraint.
• B. Apply a pulse oximeter to the right hand.
• C. Compare hand color bilaterally.
• D. Palpate the right radial pulse.

Correct answer: A

Rationale: The correct action to take first when observing blue fingers in a client with wrist restraints is to loosen the right wrist restraint. Blue fingers indicate compromised circulation, and loosening the restraint can help restore blood flow to the area. Applying a pulse oximeter (Choice B) or palpating the right radial pulse (Choice D) may be necessary following the loosening of the restraint to assess the client's oxygen saturation and pulse. Comparing hand color bilaterally (Choice C) is important but not the immediate action needed when a circulation issue is noted in one hand.

2. A nurse is preparing an education program for staff about advocacy. What information should the nurse include?

• A. Advocacy ensures clients' safety, health, and rights.
• B. Advocacy involves only supporting client complaints.
• C. Advocacy means making all decisions for the client.
• D. Advocacy is not part of nursing responsibilities.

Correct answer: A

Rationale: The correct answer is A. Advocacy in nursing involves ensuring clients' safety, health, and rights. Nurses advocate for their clients by promoting autonomy, informed decision-making, and protecting their rights. Choice B is incorrect because advocacy goes beyond just supporting client complaints; it encompasses a broader scope of ensuring holistic care and well-being. Choice C is incorrect as advocacy does not mean making all decisions for the client but rather empowering them to make informed choices. Choice D is incorrect as advocacy is a crucial component of nursing responsibilities, as it involves standing up for clients' best interests and ensuring their rights are respected.

3. When preparing an injection for opioid medication, a nurse draws 1mL from a 2mL vial. What should the nurse do next?

• A. Ask another nurse to observe medication wastage
• B. Document the amount of medication drawn on the MAR
• C. Dispose of the remaining medication in a sharps container
• D. Administer the entire vial of medication to avoid wastage

Correct answer: A

Rationale: When drawing medication from a vial, especially for controlled substances like opioids, any wastage must be witnessed by another healthcare professional to ensure accuracy, prevent diversion, and maintain safety standards. This process is crucial for proper documentation and accountability. Recording the amount drawn on the Medication Administration Record (MAR) is important for tracking administered doses and preventing errors. Disposing of the remaining medication in a sharps container is not recommended as it does not address proper wastage documentation. Administering the entire vial of medication just to avoid wastage is inappropriate and can lead to potential harm or overdose in the patient.

4. The healthcare professional is preparing to administer potassium chloride intravenously to a client with hypokalemia. Which action is most important?

• A. Monitor the client's respiratory rate
• B. Check the client's urine output
• C. Administer the potassium chloride as a rapid IV push
• D. Dilute the potassium chloride in an appropriate IV solution

Correct answer: D

Rationale: The correct answer is to dilute the potassium chloride in an appropriate IV solution. Potassium chloride should never be administered as a rapid IV push as it can lead to severe complications, including cardiac arrhythmias. Diluting the medication and administering it slowly helps reduce the risk of adverse effects. Monitoring the client's respiratory rate (Choice A) and checking urine output (Choice B) are important aspects of patient assessment but not the most crucial when administering potassium chloride. Administering potassium chloride as a rapid IV push (Choice C) is dangerous and can result in serious harm to the client.

5. When explaining the procedure for collecting a 24-hour urine specimen for creatinine clearance to an older adult male, what should the nurse do next?

• A. Assess the client for confusion and reteach the procedure
• B. Check the urine for color and texture
• C. Empty the urinal contents into the 24-hour collection container
• D. Discard the contents of the urinal

Correct answer: A

Rationale: The correct next step for the nurse is to assess the client for confusion and reteach the procedure. This is crucial to ensure that the older adult male understands the process correctly, reducing the likelihood of errors in collecting the 24-hour urine specimen for creatinine clearance. Checking the urine for color and texture (Choice B) is not the immediate next step as the focus should be on patient understanding first. Emptying the urinal contents into the 24-hour collection container (Choice C) assumes prior knowledge on the client's part and skips the critical step of ensuring comprehension. Discarding the contents of the urinal (Choice D) is incorrect and wasteful since the urine is necessary for the 24-hour collection process.

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