Nursing Elites

1. A client with a history of seizures is admitted for monitoring. What should the nurse prioritize?

• A. Ensure the client is on seizure precautions.
• B. Educate the client about seizure triggers.
• C. Monitor for signs of an impending seizure.
• D. Initiate IV access for anti-seizure medication.

Correct answer: A

Rationale: The correct answer is to ensure the client is on seizure precautions. This is crucial in preventing injury during a seizure episode. While educating the client about seizure triggers (choice B) is important for long-term management, it is not the priority when the client is admitted for monitoring. Monitoring for signs of an impending seizure (choice C) is essential but does not address immediate safety concerns. Initiating IV access for anti-seizure medication (choice D) is not the priority unless a seizure occurs and medical intervention is needed.

2. A patient on mechanical ventilation experiences a sudden drop in oxygen saturation. What should the nurse check first?

• A. Check the ventilator tubing for disconnection.
• B. Increase the patient's oxygen flow.
• C. Perform a full physical assessment.
• D. Reassess the patient's oxygen levels after 5 minutes.

Correct answer: A

Rationale: The correct answer is to check the ventilator tubing for disconnection first when a patient on mechanical ventilation experiences a sudden drop in oxygen saturation. This is crucial because equipment malfunction, such as tubing disconnection, can lead to decreased oxygen delivery, resulting in a drop in oxygen saturation. Checking the tubing ensures that the ventilation system is functioning properly and that the patient is receiving the necessary oxygen. Option B is incorrect because increasing oxygen flow without checking for equipment issues may not address the root cause of the drop in saturation. Option C is not the priority in this situation as the immediate focus should be on assessing and ensuring the functioning of the ventilation equipment. Option D delays addressing the potential equipment malfunction, which could worsen the patient's condition if not promptly resolved.

3. A client with left hemiparesis is learning how to use a cane. Which of the following instructions should the nurse include?

• A. Place the cane approximately 61 cm (24 in) in front of their feet before advancing
• B. Advance the stronger leg and the cane together to support the weaker leg
• C. Remove the rubber tip when using the cane
• D. Hold the cane on the right side to provide support for the weaker leg

Correct answer: D

Rationale: The correct way to use a cane for a client with left hemiparesis is to hold the cane on the right side to provide support for the weaker left leg. This allows for better stability and weight distribution. Placing the cane approximately 61 cm (24 in) in front of their feet before advancing (Choice A) is not necessary and may lead to improper gait. Advancing the stronger leg and the cane together (Choice B) is incorrect as it does not provide support for the weaker leg. Removing the rubber tip when using the cane (Choice C) is also incorrect as the rubber tip helps provide traction and stability.

4. A client in her first trimester of pregnancy is being taught by a nurse about over-the-counter medications that belong to pregnancy risk category B. Which of the following medications should the nurse include?

• A. Naproxen
• B. Aspirin
• C. Ibuprofen
• D. Acetaminophen

Correct answer: D

Rationale: Acetaminophen is the correct choice as it belongs to pregnancy risk category B, making it considered safe during pregnancy. Naproxen, Aspirin, and Ibuprofen are not recommended during pregnancy, especially in the first trimester, as they are classified in higher-risk categories which may be harmful to the developing fetus.

5. What is the most appropriate action for a healthcare professional to take when a medication error occurs?

• A. Document the error in the patient's medical record.
• B. Report the error to the healthcare provider immediately.
• C. Apologize to the patient and explain what happened.
• D. Continue administering the medication and monitor the patient closely.

Correct answer: B

Rationale: When a medication error occurs, the most appropriate action for a healthcare professional is to report the error to the healthcare provider immediately. This is crucial for ensuring prompt corrective action to mitigate any potential harm to the patient. Documenting the error is important but should come after reporting it to the relevant authorities. Apologizing to the patient is important for maintaining trust and communication but should not take precedence over reporting and addressing the error. Continuing to administer the medication without addressing the error is unsafe and goes against patient safety protocols.

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