Nursing Elites

1. 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.

2. People-related supervisory tasks include all of the following except:

• A. coaching
• B. encouraging
• C. target setting
• D. rewarding

Correct answer: C

Rationale: People-related supervisory tasks involve direct interaction with individuals performing the work. Coaching, encouraging, rewarding, evaluating, and facilitating are all part of these tasks as they focus on supporting and motivating employees. Target setting, on the other hand, is a task-centered responsibility that involves projecting goals or objectives to be accomplished. It focuses more on setting objectives and goals rather than directly interacting with individuals, making it the exception among the given choices.

3. An LPN is caring for a primarily bedridden client. Which finding should be of least concern?

• A. swollen feet
• B. brown discoloration above the ankles
• C. leg pain
• D. capillary refill time of 3 seconds on the big toe

Correct answer: D

Rationale: The correct answer is the capillary refill time of 3 seconds on the big toe. A capillary refill time longer than three seconds may indicate inadequate blood flow. Swollen feet, brown discoloration above the ankles, and leg pain are all signs of venous insufficiency to the lower extremities. These findings can suggest circulation issues and require further assessment and intervention. Therefore, they should be of more concern compared to the capillary refill time of 3 seconds on the big toe, which is within the normal range of 2-3 seconds.

4. Who is responsible for obtaining the signature from the client on the informed consent?

• A. the staff nurse
• B. the charge nurse
• C. the LPN
• D. the physician

Correct answer: D

Rationale: The correct answer is the physician. It is the physician's responsibility to ensure that the client provides informed consent by obtaining their signature. While nurses play a crucial role in the healthcare team, their responsibility lies in verifying that the consent process has been completed correctly and advocating for the client. The staff nurse, charge nurse, and LPN do not have the authority to obtain the client's signature on the informed consent form, as this is within the scope of practice of the physician.

5. A nurse is planning to administer an oral antibiotic to a client with a communicable disease. The client refuses the medication and tells the nurse that the medication causes abdominal cramping. The nurse responds, 'The medication is needed to prevent the spread of infection, and if you don't take it orally I will have to give it to you in an intramuscular injection.' Which statement accurately describes the nurse's response to the client?

• A. The nurse is justified in administering the medication by way of the intramuscular route because the client has a communicable disease.
• B. The nurse could be charged with assault.
• C. Assault is an intentional threat to bring about harmful or offensive contact. If a nurse threatens to give a client a medication that the client refuses or threatens to give a client an injection without the client's consent, the nurse may be charged with assault. Therefore, the nurse is not justified in administering the medication. Battery is any intentional touching without the client's consent.
• D. The nurse will be justified in administering the medication by the intramuscular route once a prescription has been obtained from the health care provider.

Correct answer: C

Rationale: The correct answer explains the concept of assault, which is an intentional threat to bring about harmful or offensive contact. In the scenario provided, the nurse's statement about administering the medication via an intramuscular injection without the client's consent constitutes a threat, potentially falling under the definition of assault. Choice A is incorrect because the nurse's action is not automatically justified solely by the client having a communicable disease. Choice D is also incorrect because even with a prescription, the nurse cannot administer the medication without the client's consent. Choice C provides a detailed explanation distinguishing assault from battery, which helps in understanding the legal implications of the nurse's response in this situation.

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