Nursing Elites

1. Which of the following is an important aspect of note-taking?

• A. Not specific and behavior-oriented
• B. Forces the manager to deal with the problem
• C. Records only undesirable events
• D. Failure to give performance feedback

Correct answer: B

Rationale: The correct answer is B: 'Forces the manager to deal with the problem.' Note-taking is essential as it compels the manager to address issues, regardless of their size or nature. This process helps in identifying, documenting, and resolving problems effectively. Choice A is incorrect because note-taking should be specific and focused on behaviors. Choice C is incorrect as note-taking should record all events, not just undesirable ones. Choice D is incorrect as it does not directly relate to the importance of note-taking in addressing problems.

2. During a home safety assessment, a nurse is evaluating a client who is receiving supplemental oxygen. Which observation should the nurse identify as a proper safety protocol?

• A. The client has a weekly inspection checklist for oxygen equipment.
• B. The client stores an extra oxygen tank on its side under their bed.
• C. The client identifies the location of a fire extinguisher.
• D. The client uses a wool blanket on their bed.

Correct answer: A

Rationale: The correct answer is A because having a weekly inspection checklist for oxygen equipment ensures that the client can monitor the safety and functionality of the oxygen equipment regularly. This is crucial for maintaining a safe environment. Choice B is incorrect because storing an extra oxygen tank on its side under the bed can pose a safety hazard, as tanks should be stored upright. Choice C is a good safety practice, but it is not directly related to oxygen use. Choice D is incorrect because wool blankets are flammable and should not be used by clients receiving supplemental oxygen due to the increased risk of fire.

3. When a client is receiving pain medication through a PCA pump, which of the following actions should the nurse take?

• A. Educate the family not to push the button for the client while the client is asleep.
• B. Explain to the client that vital signs will be monitored regularly due to being on a PCA pump.
• C. Instruct the client to push the button only when pain is above a 7 on a scale of 0 to 10.
• D. Adjust the basal rate and decrease the lock-out interval time if the client's pain level is too high.

Correct answer: D

Rationale: When a client is receiving pain medication through a PCA pump, it is essential to adjust the settings if their pain level is not adequately controlled. Increasing the basal rate and shortening the lock-out interval time can help manage the client's pain more effectively. This adjustment should be made by the healthcare provider based on the client's pain assessment and response to the current settings. It is crucial to individualize the PCA pump settings to optimize pain management for each client. Choices A, B, and C are incorrect because educating the family not to push the button, explaining vital sign monitoring, and setting a specific pain level for button pushing are not direct actions the nurse should take to adjust the PCA pump settings for effective pain management.

4. The ANA is a registered labor organization, but it does not engage in direct __________.

• A. Empower union affiliation
• B. Reward union affiliation
• C. Encourage union affiliation
• D. Collective bargaining

Correct answer: D

Rationale: The correct answer is D, 'Collective bargaining.' The American Nurses Association is a registered labor organization, but it does not engage in direct collective bargaining. The actual certification of units, negotiation of contracts, and administration of contracts is conducted by the state nurses associations (SNAs). Choices A, B, and C are incorrect as the ANA's role does not involve empowering, rewarding, or encouraging union affiliation directly.

5. A nurse is caring for a client who is postoperative and is exhibiting signs of hemorrhagic shock. The nurse notifies the surgeon, who tells the nurse to continue to measure the client's vital signs every 15 min and to report back in 1 hour. Which of the following actions should the nurse take next?

• A. Document the surgeon's instructions in the client's medical record.
• B. Complete an incident report.
• C. Consult the charge nurse.
• D. Notify the nursing manager.

Correct answer: D

Rationale: In this scenario, the nurse should notify the nursing manager next. The surgeon's instructions are related to the client's condition, and it is crucial to inform the nursing manager about the situation. Option A is incorrect because documenting the surgeon's instructions in the medical record is not the immediate next step. Option B is also incorrect as completing an incident report is not warranted in this situation. Option C is not the best choice as consulting the charge nurse may cause a delay in escalating the situation to higher management, which is necessary in cases of emergency like hemorrhagic shock.

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