Nursing Elites

1. Which of the following are included in the Rights of Medication Administration? Select all that apply.

• A. Right dose, right time, right explanation, right client, right route
• B. Right dose, right time, right client, right route
• C. Right dose, right time, right client
• D. Right time, right explanation, right client

Correct answer: B

Rationale: The Rights of Medication Administration include the right client, right drug, right dose, right route, and right time. An additional right that is sometimes included is the right documentation. The correct answer includes the essential rights that must be ensured during medication administration. Choice A is incorrect as 'right explanation' is not part of the traditional Rights of Medication Administration. Choice B is incorrect as 'right explanation' is not included, and choice C is missing the right route. Choice D is incorrect as it lacks the right dose and right route.

2. A nurse assisting with data collection of the peripheral vascular system performs the Allen test. The nurse understands that this test is used to determine the patency of which blood vessel(s)?

• A. Capillaries
• B. Pedal pulses
• C. Femoral arteries
• D. Radial and ulnar arteries

Correct answer: D

Rationale: The nurse performs the Allen test to determine the patency of the radial and ulnar arteries. During the test, the nurse applies pressure over the client's ulnar and radial arteries simultaneously. The client is then asked to open and close the hand repeatedly, causing the hand to blanch. Subsequently, the nurse releases pressure from the ulnar artery while compressing the radial artery and checks the color of the extremity distal to the pressure point. If pinkness fails to return within 6 seconds, it indicates that the ulnar artery is insufficient, suggesting that the radial artery should not be used for obtaining a blood specimen. Choice A (Capillaries) is incorrect as the Allen test assesses the patency of larger arteries, not capillaries. Choice B (Pedal pulses) is incorrect as the Allen test specifically evaluates the radial and ulnar arteries, not the pedal pulses in the foot. Choice C (Femoral arteries) is incorrect as the Allen test focuses on the radial and ulnar arteries in the hand, not the femoral arteries in the leg.

3. How often should the nurse change the intravenous tubing on total parenteral nutrition solutions?

• A. every 24 hours
• B. every 36 hours
• C. every 48 hours
• D. every 72 hours

Correct answer: A

Rationale: The correct answer is 'every 24 hours.' Changing the intravenous tubing on total parenteral nutrition solutions every 24 hours is crucial due to the high risk of bacterial growth. Bacterial contamination can lead to serious infections in patients receiving total parenteral nutrition. Choices B, C, and D are incorrect because waiting longer intervals between tubing changes increases the risk of bacterial contamination and infection, compromising patient safety. It is essential to maintain a strict 24-hour schedule to minimize the risk of complications associated with bacterial contamination.

4. A nurse is reviewing the medical record of an older client with presbycusis. Which finding would the nurse expect to note in the client's record?

• A. Difficulty hearing whispered words in the voice test
• B. Improved hearing ability during conversational speech
• C. Unilateral conductive hearing loss
• D. Difficulty hearing low-pitched tones

Correct answer: A

Rationale: Presbycusis, a sensorineural hearing loss, is the most common form of hearing loss in older adults. Typically, the loss is bilateral, resulting in difficulty hearing high-pitched tones. The condition is revealed when the client has difficulty hearing whispered words in the voice test and consonants during conversational speech. Choice A is correct because it reflects the expected finding in presbycusis. Choices B, C, and D are incorrect because presbycusis does not result in improved hearing ability during conversational speech, unilateral conductive hearing loss, or difficulty hearing low-pitched tones.

5. How should a nurse listen to the breath sounds of a client?

• A. Ask the client to lie prone.
• B. Ask the client to breathe in and out through the nose.
• C. Hold the bell of the stethoscope lightly against the chest.
• D. Listen for at least one full respiration in each location on the chest.

Correct answer: D

Rationale: To best listen to breath sounds, the nurse should have the client sit, leaning slightly forward, with arms resting comfortably across the lap. The client should be instructed to breathe through the mouth a little deeper than usual, but to stop if feeling dizzy. The nurse should hold the flat diaphragm end piece of the stethoscope firmly against the client's chest wall. It is crucial to listen for at least one full respiration in each location on the chest to assess breath sounds accurately. Side-to-side comparison is essential in breath sound assessment. Therefore, options A, B, and C are incorrect as they do not align with the correct procedure for listening to breath sounds.

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