Nursing Elites

1. Which of these should not be included when calculating a client's fluid intake?

• A. ice chips
• B. Jell-O™
• C. pudding
• D. IV fluid from an antibiotic piggyback

Correct answer: C

Rationale: Pudding is a semi-solid and does not contribute significantly to fluid intake as it does not melt at room temperature. Therefore, it should not be included in fluid intake calculations. On the other hand, ice chips, Jell-O™, and IV fluid from an antibiotic piggyback are all sources of fluid that can significantly contribute to a client's total fluid intake and should be considered when calculating it. Ice chips and Jell-O™ provide hydration upon melting, while IV fluid directly adds to the fluid volume in the body.

2. What condition is mammography used to detect?

• A. pain
• B. tumor
• C. edema
• D. epilepsy

Correct answer: B

Rationale: Mammography is specifically used to detect tumors or abnormal growths, especially in breast tissue. It is not a tool for identifying pain, edema, or epilepsy. Therefore, the correct answer is 'tumor.' Pain is a symptom, edema is swelling, and epilepsy is a neurological disorder; none of these are conditions typically detected through mammography.

3. While repositioning a comatose client, the nurse senses a tingling sensation as she lowers the bed. What action should she take?

• A. Unplug the bed's power source.
• B. Remove the client from the bed immediately.
• C. Notify the biomedical department at once.
• D. Turn off the oxygen.

Correct answer: A

Rationale: The correct action for the nurse to take when sensing a tingling sensation while lowering the bed with a comatose client is to unplug the bed's power source. This should be the initial step as there may be a fault in the bed's grounding. Removing the client from the bed immediately is not safe until the electrical issue is resolved. Notifying the biomedical department is important but should come after ensuring the immediate safety of the client. Turning off the oxygen is not necessary unless there is a specific issue related to oxygen delivery, which is not indicated in this scenario.

4. Why is accurate documentation of assessment findings regarding pressure ulcers crucial?

• A. To comply with legal requirements for documenting lesions.
• B. To meet hospital policies for documenting lesions.
• C. To fulfill physician's documentation requirements for lesions.
• D. Because the nursing assessment of ulcers is a standard of nursing practice.

Correct answer: D

Rationale: Accurate documentation of assessment findings regarding pressure ulcers is crucial because the nursing assessment of ulcers is a standard practice in nursing care. Documenting these findings not only ensures continuity of care but also plays a vital role in preventing further progression of the ulcer. Choices A, B, and C are incorrect because while laws, hospital policies, and physician requirements may influence documentation practices, the primary reason for accurate documentation lies in the standards of nursing practice and the quality of patient care.

5. While receiving an infusion of cefazolin sodium, the client complained of itchy skin. The nurse observed warm, flushed skin with a red rash on the arms, chest, and back. The health care provider was promptly notified.

• A. The client is apparently allergic to cefazolin sodium, as indicated by warm, flushed skin and a rash on the arms, chest, and back.
• B. The client had an allergy to cefazolin sodium.
• C. The health care provider was notified because a rash developed while the client was receiving cefazolin sodium.
• D. During an infusion of cefazolin sodium, the client complained that his skin was itchy. The client's skin was warm and flushed, with a red rash on the arms, chest, and back. The health care provider was notified.

Correct answer: D

Rationale: Accurate and objective documentation is essential during an incident report. Choice A makes an assumption of allergy based on subjective interpretation, which is not appropriate. Choice B states a conclusion without proper documentation. Choice C is incomplete as it fails to provide a detailed account of the observed symptoms. Choice D offers a precise description of the client's symptoms, actions taken, and notification of the healthcare provider, making it the most suitable documentation choice.

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