Nursing Elites

1. What is the most important action for the nurse to take after finding a patient on the floor who reports, 'I fell out of bed'?

• A. Reassess the patient.
• B. Complete an incident report.
• C. Notify the health care provider.
• D. Take no action, as no harm has occurred.

Correct answer: C

Rationale: The most important action for the nurse to take after finding a patient on the floor who reports falling out of bed is to notify the health care provider. This is crucial to ensure that the incident is reported, documented, and that the patient receives necessary follow-up care. Reassessing the patient is important, but notifying the healthcare provider takes precedence to address any potential injuries or issues that may have resulted from the fall. Completing an incident report is necessary, but immediate notification to the healthcare provider is more critical in this situation. Doing nothing is not an appropriate response, as the patient's safety and well-being must be the top priority.

2. A nurse in an emergency department is preparing a change-of-shift report for an adult client who is transferring to a medical-surgical unit using the SBAR communication tool. Which of the following information should the nurse include in the report?

• A. The client has a do-not-resuscitate order.
• B. The client has a continuous IV of lactated Ringer's.
• C. The client was straight catheterized for 350 mL 2 hours ago.
• D. The client has Medicare insurance.

Correct answer: A

Rationale: In an SBAR report, key information such as the client's do-not-resuscitate (DNR) status should be included as it directly impacts the client's care and treatment plan. Choices B and C are important details but may not be as critical for immediate care planning during the shift change. Choice D, the client having Medicare insurance, is important for billing purposes but does not directly impact the client's immediate care needs.

3. A nurse is caring for a client who has not voided for 8 hours following the removal of an indwelling urinary catheter. Which of the following actions should the nurse take first?

• A. Provide assistance to the bathroom
• B. Insert a straight catheter
• C. Increase fluids
• D. Perform a bladder scan

Correct answer: D

Rationale: Performing a bladder scan is the first step to assess bladder retention before any further interventions.

4. A client with hyperthyroidism is prescribed propranolol. Which finding indicates that the propranolol is effective?

• A. The client reports an increase in weight
• B. The client has a decrease in blood pressure
• C. The client reports an increase in energy
• D. The client's respiratory rate has increased

Correct answer: B

Rationale: The correct answer is B because a decrease in blood pressure is an expected outcome when propranolol, a beta-blocker, is effectively managing hyperthyroidism. Propranolol helps control symptoms such as tachycardia and hypertension associated with hyperthyroidism. Choices A, C, and D are incorrect because weight gain, increased energy, and an increased respiratory rate are not direct indicators of propranolol's effectiveness in treating hyperthyroidism.

5. A charge nurse is planning care for a group of clients on a medical-surgical unit. Which of the following tasks should the nurse delegate to an assistive personnel (AP)?

• A. Giving a glycerin suppository to a client for constipation
• B. Evaluating the effectiveness of ibuprofen administered to a client who reported a headache
• C. Discussing dietary changes with a client who has a prescription for a gluten-free diet
• D. Measuring hourly urinary output for a client who is postoperative

Correct answer: D

Rationale: The correct answer is D because measuring hourly urinary output is a task that falls within the scope of practice for assistive personnel. This task involves a technical skill that can be delegated by the charge nurse. Choices A, B, and C require higher-level nursing assessments and interventions that should be performed by licensed nursing staff. Giving a glycerin suppository involves medication administration, evaluating the effectiveness of ibuprofen requires assessment and critical thinking, and discussing dietary changes involves education and assessment of the client's understanding and compliance, all of which are beyond the scope of practice for assistive personnel.

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