Nursing Elites

1. A nurse is observing a newly licensed nurse providing care for a client who reports pain. The nurse checked the client’s MAR and noted the last dose of pain medication was administered 6 hours ago. The prescription specifies administration every 4 hours PRN for pain. The nurse administered the medication and followed up with the client 40 minutes later, who reported improvement. What did the newly licensed nurse overlook in the nursing process?

• A. Assessment
• B. Planning
• C. Intervention
• D. Evaluation

Correct answer: A

Rationale: The correct answer is 'Assessment.' In the nursing process, assessment is the first step, crucial before any intervention. Assessment involves gathering data about the client's condition to establish a baseline for evaluating responses to interventions. In this scenario, the newly licensed nurse missed assessing the client's pain intensity, location, quality, and other relevant factors before administering the pain medication. While the follow-up evaluation with the client is commendable, it cannot replace the initial assessment. Planning involves setting goals and outcomes, intervention is the action taken to achieve these goals, and evaluation assesses the client's response to the intervention.

2. A healthcare provider is caring for several clients who are receiving oxygen therapy. Which client should the provider assess most frequently for manifestations of oxygen toxicity?

• A. 100% oxygen via partial rebreathing mask
• B. 2 liters per minute via nasal cannula
• C. 4 liters per minute via simple mask
• D. 6 liters per minute via face mask

Correct answer: A

Rationale: When a client is receiving 100% oxygen via a partial rebreathing mask, there is a higher risk for oxygen toxicity due to the higher concentration of oxygen delivered. This client should be assessed most frequently for manifestations of oxygen toxicity. Choices B, C, and D are less likely to result in oxygen toxicity compared to 100% oxygen delivery via a partial rebreathing mask.

3. A patient has scaling of the scalp. Which term will the nurse use to report this finding to the oncoming staff?

• A. Dandruff
• B. Alopecia
• C. Pediculosis
• D. Xerostomia

Correct answer: A

Rationale: The correct term the nurse will use to report scaling of the scalp is 'Dandruff.' Dandruff is characterized by scaling of the scalp that is often accompanied by itching. Choice B, 'Alopecia,' refers to hair loss, not scaling. Choice C, 'Pediculosis,' is the infestation of lice, not scaling. Choice D, 'Xerostomia,' pertains to dry mouth, which is unrelated to the described symptom of scaling of the scalp.

4. A nurse obtains a prescription for wrist restraints for a client who is trying to pull out his NG Tube. Which of the following actions should the nurse take?

• A. Remove the restraints every 4 hours.
• B. Attach the restraints securely to the side of the client's bed.
• C. Apply the restraints to allow as little movement as possible.
• D. Allow room for two fingers to fit between the client's skin and the restraints.

Correct answer: D

Rationale: When using wrist restraints, it is important to allow room for two fingers to fit between the client's skin and the restraints. This practice ensures proper circulation and comfort for the client while still providing the necessary level of security. Choice A is incorrect because removing restraints every 4 hours may compromise the effectiveness of restraint use. Choice B is incorrect as restraints should not be attached to the side of the bed where they could cause harm or be tampered with by the client. Choice C is incorrect because allowing minimal movement may lead to discomfort and compromise proper circulation.

5. A client requires a 24-hour urine collection. Which statement by the client indicates an understanding of the teaching?

• A. "I had a bowel movement, but I was able to save the urine."
• B. "I have a specimen in the bathroom from about 30 minutes ago."
• C. "I flushed what I urinated at 7 a.m. and have saved all urine since."
• D. "I drink a lot, so I will fill up the bottle and complete the test quickly."

Correct answer: C

Rationale: The correct answer is C because for a 24-hour urine collection, the first void is discarded, and all subsequent urine should be saved. Choice A is incorrect because bowel movements do not contribute to a urine collection. Choice B indicates a single specimen rather than continuous collection over 24 hours. Choice D is incorrect as it incorrectly suggests rushing the test by drinking excessively.

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