Nursing Elites

1. A healthcare professional is preparing to administer medications to a client. Which of the following client identifiers should the healthcare professional use to ensure medication safety?

• A. Ask the client to state their full name.
• B. Ask the client for their date of birth.
• C. Compare the client's wristband with the medication administration record.
• D. Ask the client for their room number.

Correct answer: C

Rationale: Comparing the client's wristband with the medication administration record is a crucial step in ensuring medication safety. The wristband typically contains unique identifiers such as the client's name, date of birth, and medical record number, which should be cross-checked with the medication administration record to confirm the correct patient. Asking the client to state their name (Choice A) or date of birth (Choice B) may not be as reliable as the information can be misunderstood or miscommunicated. Asking for the room number (Choice D) is not a reliable client identifier for medication administration and does not confirm the patient's identity accurately.

2. A healthcare provider is providing discharge teaching to a client who does not speak the same language. Which of the following actions should the healthcare provider take?

• A. Use proper medical terms when providing instructions to the client.
• B. Offer written instructions in the client’s language.
• C. Direct verbal discharge instructions to the interpreter.
• D. Request that an assistive personnel interpret instructions for the client.

Correct answer: B

Rationale: The correct action for the healthcare provider when providing discharge teaching to a client who does not speak the same language is to offer written instructions in the client’s language. This approach helps ensure better comprehension and adherence to the instructions as the client can refer back to the written material for clarification. Choice A is incorrect because using proper medical terms may not be effective if the client does not understand the language. Choice C is incorrect since verbal instructions should be directed to the client for better understanding. Choice D is incorrect as assistive personnel may not be qualified or trained to provide accurate interpretation, risking miscommunication and potential errors in the instructions.

3. 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.

4. During a mass casualty event, a nurse is caring for multiple clients. Which of the following clients is the nurse’s priority?

• A. A client who received crush injuries to the chest and abdomen and is expected to die.
• B. A client who has a 4-inch laceration to the head.
• C. A client who has partial-thickness and full-thickness burns to his face, neck, and chest.
• D. A client who has a fractured fibula and tibia.

Correct answer: C

Rationale: During a mass casualty event, the priority client for the nurse is the one with partial-thickness and full-thickness burns to the face, neck, and chest. Clients with severe burns in critical areas require immediate attention due to the potential for life-threatening complications such as airway compromise, fluid loss, and infection. Crush injuries and fractures, although serious, are generally less urgent in comparison and can be managed after addressing the burns. Therefore, the client with burns to the face, neck, and chest should be the nurse's priority over the other clients described.

5. During a neurological assessment, a healthcare provider is evaluating a client's balance. Which of the following examinations should the provider use for this purpose?

• A. Romberg test
• B. Deep tendon reflexes
• C. Mini-Mental State Examination
• D. Babinski reflex

Correct answer: A

Rationale: The Romberg test is utilized to assess the client's balance and proprioception by having them stand with their eyes closed. This test helps evaluate sensory ataxia, a condition where an individual's balance is affected due to impaired sensory input. Deep tendon reflexes (Choice B) are assessed by tapping a tendon with a reflex hammer to evaluate the integrity of the spinal cord and peripheral nerves; this is not directly related to balance assessment. The Mini-Mental State Examination (Choice C) is a cognitive screening tool used to assess cognitive impairment or dementia, not balance. The Babinski reflex (Choice D) is elicited by stroking the sole of the foot to assess neurologic function, particularly in the corticospinal tract, and is not specific to balance evaluation.

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