Nursing Elites

1. A nurse is preparing change of shift report after the night shift using one SBAR communication tool. Which of the following data should the nurse include when reporting background information?

• A. “Blood pressure 160/92 mm Hg”
• B. “Start the first dose of penicillin at 1200”
• C. “Pain rating of 5 on a scale from 0 to 10”
• D. “Code status: do-not-resuscitate”

Correct answer: B

Rationale: The correct answer is B. When providing background information in a shift report using the SBAR communication tool, the nurse should include details related to medication administration and orders. This helps ensure continuity of care and accurate handover of responsibilities. Choices A, C, and D do not typically fall under background information for shift reports. A blood pressure reading, pain rating, and code status are more relevant to the patient's current condition and status, rather than background information about medications or orders.

2. A client reports insomnia. Which of the following actions should the nurse perform shortly before bedtime?

• A. Provide a late supper
• B. Offer a wet washcloth for the client to wash their face
• C. Perform range of motion exercises
• D. Prepare a hot cocoa or tea for the client

Correct answer: B

Rationale: Offering a wet washcloth for the client to wash their face is a soothing and calming activity that can help the client relax before bedtime, promoting better sleep. Providing a late supper can lead to indigestion and disrupt sleep. Performing range of motion exercises may increase alertness rather than promoting relaxation. Preparing a hot cocoa or tea containing caffeine close to bedtime can interfere with falling asleep.

3. When should discharge planning for a client experiencing an exacerbation of heart failure be initiated?

• A. During the admission process
• B. After the client is stabilized
• C. When the client expresses readiness to go home
• D. Just before the expected discharge date

Correct answer: A

Rationale: Discharge planning for a client with an exacerbation of heart failure should begin during the admission process. Initiating discharge planning early ensures a smooth transition and continuity of care for the client. Option B, after the client is stabilized, is not ideal because planning should start early to address potential barriers to discharge. Option C, when the client expresses readiness to go home, may be too late as discharge planning is a proactive process. Option D, just before the expected discharge date, does not allow enough time for comprehensive planning and coordination of post-discharge care needs.

4. A client has a sodium level of 125. What findings should the nurse expect?

• A. Abdominal cramping
• B. Elevated blood pressure
• C. Decreased heart rate
• D. Increased thirst

Correct answer: A

Rationale: Low sodium levels (hyponatremia) often present with various symptoms, including abdominal cramping. Abdominal cramping is a common manifestation of hyponatremia due to the altered electrolyte balance. Option B ('Elevated blood pressure') is incorrect because low sodium levels typically lead to decreased blood pressure, not elevated. Option C ('Decreased heart rate') is incorrect as low sodium levels are more likely to cause an irregular heart rate rather than a decreased heart rate. Option D ('Increased thirst') is incorrect because excessive thirst is more commonly associated with high sodium levels (hypernatremia) rather than low sodium levels.

5. The nurse is preparing to assist a newly admitted client with personal hygiene measures. The nurse wants to assess the client's gag reflex. Which action should the nurse include?

• A. Offer small sips of water through a straw
• B. Place tongue blade on back half of tongue
• C. Use a penlight to observe back of the oral cavity
• D. Auscultate breath sounds after the client swallows

Correct answer: B

Rationale: The correct action for the nurse to include when assessing the client's gag reflex is to place a tongue blade on the back half of the tongue. This method effectively tests the gag reflex without causing discomfort. Choice A is incorrect because offering small sips of water through a straw does not assess the gag reflex. Choice C is incorrect as using a penlight to observe the back of the oral cavity does not directly assess the gag reflex. Choice D is incorrect since auscultating breath sounds after the client swallows does not evaluate the gag reflex.

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