Nursing Elites

1. A client with a nasogastric (NG) tube begins vomiting. What action should the nurse take?

• A. Retape the NG tube.
• B. Clamp the NG tube.
• C. Remove the NG tube.
• D. Check the NG tube placement.

Correct answer: D

Rationale: When a client with a nasogastric (NG) tube begins vomiting, the nurse should first check the NG tube placement. Vomiting can be a sign of tube displacement, which can lead to serious complications. Retaping the tube (Choice A), clamping it (Choice B), or removing it (Choice C) without first assessing its placement can be harmful or ineffective. Checking the NG tube placement is crucial as it ensures that the tube is in the correct position and prevents potential complications. Retaping the NG tube (Choice A) is incorrect because the priority is to check the placement first. Clamping the NG tube (Choice B) or removing it (Choice C) without verifying the placement can be dangerous if the tube is dislodged. Thus, these actions should not be taken before confirming the tube's position.

2. Once the nurse has made initial rounds and checked all of the assigned clients, which client should be cared for first?

• A. A client who is scheduled for surgery at 1 p.m.
• B. A client in skeletal traction who has just received pain medication
• C. A client scheduled for physical therapy at 11 a.m.
• D. A client who is able to perform activities of daily living independently

Correct answer: A

Rationale: The priority should be given to the client who is scheduled for surgery at 1 p.m. Preparing a client for surgery involves various tasks such as physical and emotional preparation, following healthcare provider instructions, and potential last-minute changes in the surgical schedule. It is crucial to ensure the client is adequately prepared. Providing care to a client who just received pain medication can wait until the medication takes effect. Clients who are independent in performing daily activities and those scheduled for physical therapy later in the morning are not as high a priority as preparing a client for an upcoming surgery. Therefore, the client scheduled for surgery should be cared for first to ensure all necessary preparations are completed.

3. In a community hospital, a nurse is employed as a staff nurse and is supervised by a nurse manager. The nurse understands that in this position, the term authority most appropriately refers to which description?

• A. Accepting responsibility for the actions of others
• B. The official power to ensure that an organizational decision is enforced
• C. Bearing the legal responsibility for others' performance of tasks
• D. Taking responsibility for what staff members do

Correct answer: B

Rationale: The term authority refers to the official power of an individual to approve or command an action or to ensure that a decision is enforced. In the context of the nurse's position supervised by a nurse manager, having authority means having the official power to ensure that organizational decisions are carried out. Choice A, accepting responsibility for the actions of others, is more related to accountability rather than authority. Choice C, bearing the legal responsibility for others' performance of tasks, is more about legal liability rather than authority. Choice D, taking responsibility for what staff members do, is similar to choice A and is more about accountability rather than having the official power to enforce decisions. Therefore, the correct answer is B as it directly relates to the concept of authority in the context described.

4. A child comes to the clinic with a skin rash. The maculopapular lesions are distributed around the mouth and have honey-colored drainage. The caregiver states that the rash is getting worse and seems to spread with the child's scratching. Which of the following advisory comments should be given?

• A. The history and presentation might indicate chickenpox, a highly contagious disease.
• B. The lesions might indicate a noncontagious infection that does not require isolation.
• C. The history and presentation might indicate an infectious illness called impetigo.
• D. The lesions are not contagious unless others have open wounds or lesions themselves.

Correct answer: C

Rationale: The scenario describes classic impetigo, which typically presents with maculopapular lesions around the mouth with honey-colored drainage, worsening with scratching. It is important to advise the caregiver that the history and presentation are indicative of impetigo, an infectious skin condition caused by bacteria. Treatment usually involves antibiotic therapy. Choice A is incorrect because chickenpox typically presents with a vesicular rash following a history of high fever. Choice B is incorrect as impetigo is contagious and requires precautions to prevent the spread of infection. Choice D is incorrect as impetigo is contagious irrespective of open wounds or lesions in others.

5. What is distraction therapy?

• A. Focusing one's attention on stimuli other than pain.
• B. Cognitive reappraisal.
• C. The replacement of positive images of pain with other images.
• D. The use of medication and meditation.

Correct answer: A

Rationale: Distraction therapy involves directing attention away from pain towards positive stimuli, which can help reduce the perception of pain. Choice A is the correct answer as it accurately defines distraction therapy. Cognitive reappraisal (Choice B) involves changing the way one thinks about a situation to alter its emotional impact, which is different from distraction therapy. Choice C is incorrect because distraction therapy does not involve replacing images of pain with other images, but rather focusing on something unrelated. Choice D is incorrect as distraction therapy does not necessarily involve medication or meditation, but rather the redirection of attention.

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