Nursing Elites

1. A nurse is assigned to care for four clients. Which client should the nurse assess first?

• A. A client with chest pain and shortness of breath
• B. A client with a fever of 100°F
• C. A client scheduled for surgery
• D. A client with stable vital signs

Correct answer: A

Rationale: The correct answer is A. Chest pain and shortness of breath are symptoms that could indicate a life-threatening condition such as a heart attack or pulmonary embolism. Therefore, this client should be assessed first to ensure prompt intervention and treatment. Choice B, a client with a fever of 100°F, may indicate an infection but is not immediately life-threatening compared to the symptoms of chest pain and shortness of breath. Choice C, a client scheduled for surgery, is not an immediate priority unless there are specific preoperative assessments or interventions required. Choice D, a client with stable vital signs, does not indicate an urgent need for assessment compared to the client with chest pain and shortness of breath.

2. What is the most important action for the nurse to take after finding a patient on the floor who reports, 'I fell out of bed'?

• A. Reassess the patient.
• B. Complete an incident report.
• C. Notify the health care provider.
• D. Take no action, as no harm has occurred.

Correct answer: C

Rationale: The most important action for the nurse to take after finding a patient on the floor who reports falling out of bed is to notify the health care provider. This is crucial to ensure that the incident is reported, documented, and that the patient receives necessary follow-up care. Reassessing the patient is important, but notifying the healthcare provider takes precedence to address any potential injuries or issues that may have resulted from the fall. Completing an incident report is necessary, but immediate notification to the healthcare provider is more critical in this situation. Doing nothing is not an appropriate response, as the patient's safety and well-being must be the top priority.

3. The patient experienced a surgical procedure, and Betadine was utilized as the surgical prep. Two days postoperatively, the nurse's assessment indicates that the incision is red and has a small amount of purulent drainage. The patient reports tenderness at the incision site. The patient's temperature is 100.5°F, and the WBC is 10,500/mm³. Which action should the nurse take first?

• A. Reevaluate the temperature and white blood cell count in 4 hours.
• B. Check which solution was used for skin preparation in surgery.
• C. Plan to change the surgical dressing during the shift.
• D. Utilize SBAR to notify the primary health care provider.

Correct answer: D

Rationale: The patient is showing signs of a possible surgical site infection, including redness, purulent drainage, tenderness, elevated temperature, and increased white blood cell count. These symptoms suggest the need for immediate action to address a potential complication. Utilizing SBAR to notify the primary health care provider is crucial as it allows for effective communication of the patient's condition and the need for further assessment and intervention. Reevaluating the temperature and white blood cell count later, checking the solution used for skin preparation, or planning to change the dressing do not address the urgent need for intervention and communication with the healthcare provider.

4. A client asks about becoming an organ donor. What information should the nurse provide?

• A. The process should be discussed with family first.
• B. The organ donation process should begin immediately.
• C. Organ donation can proceed even if the family disagrees.
• D. Donor cards must be signed in the presence of a witness.

Correct answer: D

Rationale: The correct answer is D. For organ donation to be legally valid, the donor must sign consent documents in the presence of a witness. Choice A is incorrect because while discussing with family is important, it is not a legal requirement for organ donation. Choice B is incorrect as the organ donation process involves various steps and procedures that cannot begin immediately. Choice C is incorrect because organ donation typically requires consent and cooperation from the family if the donor is unable to provide consent.

5. A nurse is preparing to administer a blood transfusion. What is the most important action to ensure patient safety?

• A. Check the patient's vital signs every 15 minutes during the transfusion.
• B. Verify the patient's identity with two identifiers before starting the transfusion.
• C. Ensure the blood product is administered within 4 hours of removal from the blood bank.
• D. Ensure the patient has signed the informed consent form.

Correct answer: B

Rationale: The most important action to ensure patient safety when administering a blood transfusion is to verify the patient's identity with two identifiers before starting the transfusion. This step is crucial to prevent transfusion errors, such as giving the blood to the wrong patient. Checking vital signs, ensuring timely administration, and confirming informed consent are also important aspects of blood transfusion safety but verifying the patient's identity is the highest priority to prevent errors.

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