Nursing Elites

1. A nurse enters a client's room and finds her on the floor. The client's roommate reports that the client fell out of bed. Which of the following statements should the nurse document?

• A. “Client found lying on the floor.”
• B. “Client fell out of bed and was found on the floor.”
• C. “Client experienced a fall from the bed.”
• D. “Client was discovered on the floor following a fall from the bed.”

Correct answer: B

Rationale: The correct answer is B. The documentation should be clear and precise, providing details about the context of the fall. Choice A is vague and does not specify the cause of the client being on the floor. Choice C is less specific and does not directly state that the client fell from the bed. Choice D is wordy and less direct compared to option B, which clearly states that the client fell out of bed and was found on the floor.

2. A nurse on a medical-surgical unit is receiving a change-of-shift report for four clients. Which of the following clients should the nurse see first?

• A. A client who has new onset of dyspnea 24 hours after a total hip arthroplasty
• B. A client who has acute abdominal pain rated 4 on a scale from 0 to 10
• C. A client who has a UTI and low-grade fever
• D. A client who has pneumonia and an oxygen saturation of 96%

Correct answer: A

Rationale: The nurse should prioritize seeing the client who has new onset dyspnea 24 hours after a total hip arthroplasty first. This sudden dyspnea could indicate a serious complication like a pulmonary embolism, which requires immediate assessment and intervention. Acute abdominal pain, a UTI with a low-grade fever, and pneumonia with an oxygen saturation of 96% are important concerns but are not as immediately life-threatening as potential pulmonary embolism indicated by sudden dyspnea postoperatively.

3. A male client being discharged with a prescription for the bronchodilator theophylline tells the nurse that he understands he is to take three doses of the medication each day. Since timed-release capsules are not available at the time of discharge, which dosing schedule should the LPN advise the client to follow?

• A. 9 a.m., 1 p.m., and 5 p.m.
• B. 8 a.m., 4 p.m., and midnight.
• C. Before breakfast, before lunch, and before dinner.
• D. With breakfast, with lunch, and with dinner.

Correct answer: B

Rationale: The correct dosing schedule for the client to follow is to take the medication at 8 a.m., 4 p.m., and midnight. This timing spaces the doses evenly over the waking hours, ensuring consistent therapeutic levels of the medication. Choice A (9 a.m., 1 p.m., and 5 p.m.) does not evenly distribute the doses throughout the day. Choices C (Before breakfast, before lunch, and before dinner) and D (With breakfast, with lunch, and with dinner) do not provide the required frequency of dosing needed for optimal therapeutic effect.

4. Before administering the prescribed morphine sulfate to a client post-op following laparotomy who reports pain and dry mouth, what should the nurse do first?

• A. Measure the client's vital signs.
• B. Assess the client's pain level.
• C. Verify the morphine order with another nurse.
• D. Check the client's last dose of morphine.

Correct answer: A

Rationale: Before administering morphine sulfate, it is crucial to measure the client's vital signs to ensure that the client is stable and safe to receive the medication. This step helps identify any contraindications or abnormalities that could affect the administration of morphine. Assessing the client's pain level (choice B) is important, but ensuring the client's physiological stability takes precedence. Verifying the morphine order with another nurse (choice C) and checking the client's last dose of morphine (choice D) are important steps but are not the priority before administering the medication.

5. The nurse is caring for a client with a nasogastric (NG) tube. Which action should the nurse take to maintain patency of the tube?

• A. Flush the tube with 30 ml of water before and after medication administration.
• B. Administer the medication with food to prevent nausea.
• C. Verify tube placement by aspirating stomach contents.
• D. Dilute the medication with normal saline before administration.

Correct answer: A

Rationale: To maintain the patency of a nasogastric (NG) tube, it is essential to flush the tube with 30 ml of water before and after medication administration. This action helps ensure that the tube remains open and free from blockages. Flushing the tube prevents any medication residue from causing blockages, maintaining its patency. Choice B is incorrect because administering medication with food does not relate to maintaining tube patency. Choice C is incorrect as verifying tube placement by aspirating stomach contents is related to confirming correct tube placement, not maintaining patency. Choice D is also incorrect because diluting the medication with normal saline is not primarily aimed at maintaining the tube's patency.

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