Nursing Elites

1. Which nursing action will best promote patient safety when administering medications?

• A. Check the patient's wristband before administering medications.
• B. Confirm the patient's allergies prior to administration.
• C. Document the medications immediately after administration.
• D. Prepare medications at the medication cart to minimize distractions.

Correct answer: B

Rationale: Confirming the patient's allergies before administering medications is crucial for patient safety as it helps prevent adverse reactions. Checking the patient's wristband is important for identification but may not directly impact medication safety. Documenting medications after administration is necessary but does not primarily promote safety during administration. Preparing medications at the medication cart, rather than the nurse's station, is preferred to ensure accuracy and proper medication handling, but it is not directly related to confirming allergies for safety.

2. What are the priority nursing assessments for a patient who has just undergone major surgery?

• A. Providing analgesia as prescribed
• B. Monitoring for signs of infection
• C. Assessing the surgical site for bleeding
• D. Monitoring the patient's vital signs

Correct answer: B

Rationale: The correct answer is to monitor for signs of infection. After major surgery, one of the priority nursing assessments is to watch for signs of infection, such as increased temperature, redness, swelling, or drainage at the surgical site. While providing analgesia is important for pain management, monitoring for infection takes precedence as it can lead to severe complications if not detected early. Assessing the surgical site for bleeding is crucial but is usually more relevant immediately after surgery. Monitoring the patient's vital signs is essential, but the specific focus on infection assessment is crucial in the immediate postoperative period.

3. A nurse is preparing to administer enoxaparin to a client. Which of the following actions should the nurse plan to take?

• A. Aspirate for a blood return before depressing the plunger
• B. Insert the needle at a 45-degree angle
• C. Administer the medication 2.54 cm (1 in) from the umbilicus
• D. The nurse should not expel the air bubble in the prefilled syringe

Correct answer: D

Rationale: The correct action when administering enoxaparin is not to expel the air bubble in the prefilled syringe. Expelling the air bubble may lead to the loss of medication and result in an incomplete dose. Aspirating for a blood return (Choice A) is not necessary for subcutaneous injections like enoxaparin. Inserting the needle at a 45-degree angle (Choice B) is not specific to administering enoxaparin. Administering the medication 2.54 cm (1 in) from the umbilicus (Choice C) is not a standard guideline for enoxaparin administration.

4. A healthcare provider is completing discharge teaching to a client about nutrition therapy for wound healing following major surgery. Which of the following vitamins that promote wound healing should the healthcare provider include in the teaching? (SATA)

• A. Vitamin B12
• B. Vitamin C
• C. Vitamin K
• D. Vitamin D

Correct answer: B

Rationale: The correct answer is Vitamin C. Vitamin C is essential for wound healing due to its role in collagen production. Collagen is crucial for wound repair and the formation of new tissue. Vitamin B12 is important for nerve function and DNA synthesis but is not directly related to wound healing. Vitamin K is essential for blood clotting and bone health but does not directly promote wound healing. Vitamin D plays a role in bone health and immune function but is not a primary vitamin involved in wound healing.

5. Which finding in a postoperative patient requires immediate intervention by the nurse?

• A. Heart rate of 88 beats per minute.
• B. Blood pressure of 130/80 mmHg.
• C. Crackles heard in the lung bases.
• D. Oxygen saturation of 88% on room air.

Correct answer: D

Rationale: In a postoperative patient, an oxygen saturation level of 88% on room air indicates a significant drop below the normal range, suggesting potential respiratory distress. This finding requires immediate intervention by the nurse to ensure the patient receives adequate oxygenation. A heart rate of 88 beats per minute is within the normal range, making it a less concerning finding. A blood pressure of 130/80 mmHg falls within the normal range for blood pressure and does not require immediate intervention. Crackles heard in the lung bases may indicate fluid accumulation but may not always require immediate intervention unless accompanied by other concerning signs or symptoms.

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