Nursing Elites

1. Which nursing action is essential when administering a blood transfusion?

• A. Ensure the blood is administered within 4 hours.
• B. Check the patient's vital signs every 30 minutes during the transfusion.
• C. Administer the transfusion at a slow rate for the first 15 minutes.
• D. Document the transfusion in the patient's medical record immediately after administration.

Correct answer: C

Rationale: The correct answer is to administer the transfusion at a slow rate for the first 15 minutes. This practice is crucial as it helps in detecting any adverse reactions early on. Checking the patient's vital signs every 30 minutes (choice B) is important but not as essential as ensuring a slow rate at the beginning. Administering blood within 4 hours (choice A) is a standard practice but not directly related to the initial administration. Documenting the transfusion immediately (choice D) is necessary but does not directly impact the safety of the initial administration.

2. A nurse manager assigns a task outside the scope of a nursing assistant. How should the assistant respond?

• A. Refuse the task and report it to the charge nurse.
• B. Perform the task without reporting.
• C. Ask another nurse to perform the task.
• D. Accept the task but document it later.

Correct answer: A

Rationale: When a task is assigned that is outside the scope of a nursing assistant, it is essential for the assistant to refuse the task and report it to the charge nurse. This ensures that tasks are appropriately delegated, maintaining patient safety and adherence to professional standards. Performing the task without reporting can lead to potential risks for the patient and legal implications. Asking another nurse to perform the task may not address the issue of improper delegation. Accepting the task but documenting it later does not resolve the immediate concern of working within the assistant's scope of practice and seeking appropriate delegation.

3. When caring for a patient with a colostomy, which nursing action is most important?

• A. Monitor the colostomy for signs of infection.
• B. Empty the colostomy bag when it is half full.
• C. Encourage the patient to eat smaller, more frequent meals.
• D. Apply a skin barrier to prevent irritation.

Correct answer: B

Rationale: Emptying the colostomy bag when it is half full is the most important nursing action when caring for a patient with a colostomy. This practice helps prevent leakage, reduces the risk of skin irritation, and promotes patient comfort. Monitoring for signs of infection (Choice A) is essential but not as crucial as maintaining proper colostomy care. Encouraging the patient to eat smaller, more frequent meals (Choice C) can be beneficial for colostomy patients but is not as critical as ensuring timely emptying of the colostomy bag. Applying a skin barrier to prevent irritation (Choice D) is important, but ensuring timely emptying of the colostomy bag takes precedence in preventing complications associated with a colostomy.

4. Which action by the nurse represents the ethical principle of beneficence?

• A. Ensuring all clients are treated fairly
• B. Preventing harm by providing accurate information
• C. Allowing the client to refuse treatment
• D. Ensuring the client's family agrees with the treatment

Correct answer: B

Rationale: The correct answer is B. Beneficence is the ethical principle of doing good or acting in the best interest of the client. Preventing harm by providing accurate information and necessary care aligns with the principle of beneficence, as it focuses on promoting the well-being and safety of the client. Choices A, C, and D do not directly reflect the concept of beneficence. Ensuring all clients are treated fairly relates more to justice, allowing the client to refuse treatment pertains to autonomy, and ensuring the client's family agrees with the treatment involves collaboration and communication but not specifically beneficence.

5. A patient may need restraints. Which task can the nurse delegate to a nursing assistive personnel?

• A. Determining the need for restraints
• B. Obtaining an order for a restraint
• C. Assessing the patient's orientation
• D. Applying the restraint

Correct answer: D

Rationale: The correct answer is applying the restraint (Choice D). Nursing assistive personnel can be delegated the task of applying restraints under the supervision and direction of a nurse. Determining the need for restraints (Choice A) and obtaining an order for a restraint (Choice B) involve clinical judgment and assessment, which are responsibilities of the nurse. Assessing the patient's orientation (Choice C) also requires a level of assessment that should be performed by a nurse.

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