Nursing Elites

1. A charge nurse is talking with a newly licensed nurse and is reviewing nursing interventions that do not require a provider’s prescription. Which of the following interventions should the charge nurse include?

• A. Writing a prescription for morphine sulfate as needed for pain
• B. Inserting a nasogastric (NG) tube to relieve gastric distention
• C. Showing a client how to use progressive muscle relaxation
• D. Performing a daily bath after the evening meal

Correct answer: C

Rationale: The correct answer is C. Showing a client how to use progressive muscle relaxation is an intervention that does not require a provider's prescription. This falls within the nurse's scope of practice and can be implemented to promote relaxation and reduce stress for the client. Choices A and B involve tasks that require a provider's prescription and specialized training. Writing a prescription for morphine sulfate and inserting an NG tube should only be done by authorized healthcare providers. Choice D, performing a daily bath, while within the nurse's scope, does not specifically address interventions that do not require a provider's prescription.

2. A healthcare provider is assessing a client's ability to balance. Which of the following actions is appropriate when the healthcare provider conducts a Romberg test?

• A. Ask the client to extend their arms in front of their body.
• B. Ask the client to walk in a straight line heel to toe.
• C. Have the client stand with their feet together.
• D. Have the client place their hands on their hips.

Correct answer: C

Rationale: The Romberg test is a neurological test that assesses proprioception and balance. To perform this test, the client is asked to stand with their feet together and arms at their sides while closing their eyes. By removing visual input, the test challenges the vestibular and proprioceptive systems. Choices A, B, and D are incorrect because they do not align with the proper procedure for conducting the Romberg test. Extending arms in front, walking heel to toe, or placing hands on hips are not part of the Romberg test protocol and may introduce variables that could affect the assessment of balance.

3. A client returns from surgery with two Penrose drains in place. Anticipating frequent dressing changes, what should the nurse use around the incision site?

• A. Montgomery straps
• B. Sterile gauze
• C. Adhesive tape
• D. Elastic bandages

Correct answer: A

Rationale: Montgomery straps are the correct choice in this scenario. They are specifically designed to secure dressings around drain sites, like Penrose drains, and are ideal for frequent dressing changes. Sterile gauze (Choice B) is commonly used for wound dressings but may not provide the best securement for drains. Adhesive tape (Choice C) can cause skin irritation and may not be suitable for securing drains. Elastic bandages (Choice D) are typically used for compression or support but are not appropriate for securing dressings around drain sites.

4. While assisting a client with a meal, the client suddenly grabs at their neck with both hands and appears frightened. The appropriate nursing action is to:

• A. Ask the client if they are choking
• B. Perform abdominal thrusts
• C. Call for emergency help
• D. Check the client’s airway

Correct answer: A

Rationale: The correct action when a client suddenly grabs at their neck and appears frightened is to ask if they are choking. This allows the nurse to gather more information from the client directly. Performing abdominal thrusts (choice B) should only be done if the client is unable to speak, cough, or breathe. Calling for emergency help (choice C) should be done after assessing the situation and confirming choking. Checking the client's airway (choice D) is important but should come after confirming that the client is choking.

5. A nurse in a provider's office is obtaining the health and medication history of a client who has a respiratory infection. The client tells the nurse that she is not aware of any allergies, but that she did develop a rash the last time she was taking an antibiotic. Which of the following information should the nurse give to the client?

• A. We need to document the exact medication you were taking because you might be allergic to it.
• B. You should take a different type of antibiotic this time.
• C. A rash is a common reaction and is not usually concerning.
• D. You can take the same antibiotic again if needed.

Correct answer: A

Rationale: The nurse should advise the client to document the exact medication taken to identify potential allergies and prevent adverse reactions. This is important as the client developed a rash previously while taking an antibiotic, indicating a possible allergic reaction. Choice B is not appropriate as switching antibiotics without proper evaluation can be risky. Choice C is incorrect as rashes should not be dismissed without further investigation, especially in the context of taking medication. Choice D is also not recommended as re-taking the same antibiotic without clarifying the allergic reaction can lead to a potentially severe outcome.

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