Nursing Elites

1. A nurse is assessing a postoperative patient for signs of infection. Which finding is most concerning?

• A. Mild redness at the incision site.
• B. Increased drainage from the surgical site.
• C. Fever of 101°F.
• D. Normal white blood cell count.

Correct answer: C

Rationale: A fever of 101°F is the most concerning finding when assessing a postoperative patient for signs of infection. Fever can indicate an inflammatory response to an infection, and in a postoperative patient, it can signal a surgical site infection or a systemic infection. Prompt attention is necessary to prevent complications such as sepsis. Mild redness at the incision site and increased drainage can be expected in the early postoperative period due to the normal healing process. A normal white blood cell count does not rule out infection as it can be influenced by various factors, and some infections may not initially cause a rise in white blood cells.

2. What is the primary focus of secondary prevention in community mental health care?

• A. Teaching stress-reduction techniques
• B. Early detection of mental illness
• C. Leading support groups for clients with substance use disorder
• D. Rehabilitation and prevention of further issues

Correct answer: B

Rationale: The correct answer is B: Early detection of mental illness. Secondary prevention in community mental health care focuses on identifying mental health issues at an early stage to provide timely interventions. Choice A, teaching stress-reduction techniques, is more aligned with primary prevention aimed at preventing the onset of mental health problems. Choice C, leading support groups for clients with substance use disorder, pertains more to providing specific interventions for individuals with substance use issues rather than the general focus of secondary prevention. Choice D, rehabilitation and prevention of further issues, is more related to tertiary prevention, which involves addressing existing mental health conditions and preventing complications or recurrence.

3. A nurse is preparing to administer medication to a client by nasogastric tube. What should the nurse do first?

• A. Administer the medication without further assessment.
• B. Check the tube placement before administering any medication.
• C. Administer the medication in liquid form only.
• D. Administer half the dosage as a precaution.

Correct answer: B

Rationale: The correct answer is B: Check the tube placement before administering any medication. Before administering medication through a nasogastric tube, the nurse must first verify the tube's correct placement to ensure the medication reaches the stomach and to prevent complications such as aspiration. Options A, C, and D are incorrect because administering medication without confirming proper tube placement can lead to serious consequences for the client.

4. A nurse in a clinic is caring for a client who has a urinary tract infection (UTI). Which of the following prescriptions should the nurse verify with a provider?

• A. Trimethoprim-sulfamethoxazole
• B. Hyoscyamine
• C. Oxybutynin
• D. Phenazopyridine

Correct answer: C

Rationale: The correct answer is C, Oxybutynin. Oxybutynin can worsen urinary retention, so the nurse should verify this prescription with the provider. Trimethoprim-sulfamethoxazole (Choice A) is a common antibiotic used to treat UTIs and does not require verification. Hyoscyamine (Choice B) is an anticholinergic medication used for bladder spasms and does not typically worsen UTI symptoms. Phenazopyridine (Choice D) is a urinary analgesic that helps relieve pain, burning, and discomfort caused by a UTI, which may not necessarily require verification in this scenario.

5. A nurse manager assigns a task outside the scope of a nursing assistant. How should the assistant respond?

• A. Refuse the task and report it to the charge nurse.
• B. Perform the task without reporting.
• C. Ask another nurse to perform the task.
• D. Accept the task but document it later.

Correct answer: A

Rationale: When a task is assigned that is outside the scope of a nursing assistant, it is essential for the assistant to refuse the task and report it to the charge nurse. This ensures that tasks are appropriately delegated, maintaining patient safety and adherence to professional standards. Performing the task without reporting can lead to potential risks for the patient and legal implications. Asking another nurse to perform the task may not address the issue of improper delegation. Accepting the task but documenting it later does not resolve the immediate concern of working within the assistant's scope of practice and seeking appropriate delegation.

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