Nursing Elites

1. A nurse is caring for a client who is requesting to leave the facility against medical advice (AMA). The client states, 'I am ready to go immediately.' Which of the following actions should the nurse take first?

• A. Teach the client about the potential health risks of leaving early
• B. Ask the client to sign a document stating they are leaving AMA
• C. Document the client's statement in direct quotes in the medical record
• D. Complete an incident report detailing the client scenario

Correct answer: A

Rationale: The correct action for the nurse to take first is to educate the client about the potential health risks of leaving against medical advice (AMA). By providing this information, the nurse can help the client make an informed decision regarding their healthcare. Choice B, asking the client to sign a document, can be done after the client has been informed about the risks. Choice C, documenting the client's statement, is important but should not take precedence over educating the client. Choice D, completing an incident report, is not the priority when a client is requesting to leave AMA.

2. A nurse is preparing to administer ampicillin 500 mg IV bolus every 6 hours. Available is ampicillin 500 mg in 50 mL dextrose 5% in water (D5W) to infuse over 20 minutes. The nurse should set the IV pump to deliver how many mL/hr?

• A. 100 mL/hr
• B. 150 mL/hr
• C. 200 mL/hr
• D. 250 mL/hr

Correct answer: B

Rationale: To infuse 50 mL over 20 minutes, the pump should be set to 150 mL/hr. This calculation ensures the correct rate for the infusion of the medication. Choices A, C, and D are incorrect as they do not align with the correct calculation based on the given information.

3. A nurse manager assigns a nursing assistant a task outside of their role. What should the nursing assistant do?

• A. Follow the manager's directive
• B. Report the task to the charge nurse
• C. Refuse to perform the task
• D. Perform the task and document later

Correct answer: B

Rationale: If a nurse manager assigns a nursing assistant a task that is outside of their role, the nursing assistant should report the task to the charge nurse. This is important because the charge nurse can provide guidance on whether the task is appropriate for the nursing assistant to perform. Choice A is incorrect because blindly following a directive that is outside of the nursing assistant's scope could lead to negative consequences. Choice C might not be the best course of action initially, as it's important to seek clarification first. Choice D is also not the best option because performing a task outside of one's role without proper authorization can pose risks to both the patient and the nursing assistant.

4. A nurse is caring for a patient who is postoperative day 1 following abdominal surgery. What is the nurse's priority action to prevent complications?

• A. Encourage the patient to perform incentive spirometry.
• B. Assist the patient in ambulating around the unit.
• C. Reposition the patient every 2 hours.
• D. Administer pain medication as prescribed.

Correct answer: A

Rationale: The correct answer is to encourage the patient to perform incentive spirometry. Incentive spirometry helps prevent respiratory complications, such as atelectasis, by promoting deep breathing and optimal lung expansion. Ambulating, repositioning, and administering pain medication are important interventions but do not take precedence over preventing respiratory complications in the immediate postoperative period.

5. What is an expected finding during the assessment of a client transitioning into a new role?

• A. The client's ability to express feelings of guilt
• B. Presence of suicidal or homicidal ideation
• C. Changes in coping skills over the past few weeks
• D. Client's involvement in community activities

Correct answer: B

Rationale: During a client's transition into a new role, the presence of suicidal or homicidal ideation should be assessed due to the increased risk associated with significant life changes. This finding could indicate a need for immediate intervention. While assessing the client's ability to express feelings of guilt is important, it may not be the most critical aspect during this specific assessment. Changes in coping skills over time are relevant but might not be the primary focus during a role transition assessment. The client's involvement in community activities, although beneficial for social support, is not directly related to the immediate concerns of assessing a client transitioning into a new role.

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