Nursing Elites

1. A healthcare professional is preparing to perform nasal tracheal suctioning for a client. Which of the following is an appropriate action for the healthcare professional to take?

• A. Hold the suction catheter with the non-dominant hand.
• B. Apply suctioning for 20 to 30 seconds.
• C. Place the catheter in a clean and dry location for later use.
• D. Use surgical asepsis when performing the procedure.

Correct answer: D

Rationale: Using surgical asepsis when performing nasal tracheal suctioning is crucial to prevent infection. Choice A is incorrect because the suction catheter should be held with the dominant hand to ensure better control and precision during the procedure. Choice B is incorrect as suctioning should be applied for no longer than 10 to 15 seconds to avoid trauma to the mucous membranes. Choice C is incorrect as the catheter should be disposed of properly after single-use to prevent cross-contamination and infection.

2. The caregiver is teaching parents about accidental poisoning in children. Which point should be emphasized?

• A. Call the Poison Control Center as soon as the situation is identified
• B. Empty the child's mouth in any case of possible poisoning
• C. Have the child move minimally if a toxic substance was inhaled
• D. Do not induce vomiting if the poison is a hydrocarbon

Correct answer: B

Rationale: The correct answer is to emphasize emptying the child's mouth in any case of possible poisoning. This action is crucial to prevent further ingestion of the poisonous substance. Choice A is incorrect because calling the Poison Control Center should be one of the first steps, not waiting until the situation is identified. Choice C is incorrect as moving the child may spread or exacerbate the effects of the toxic substance. Choice D is incorrect because inducing vomiting can be harmful if the poison is a hydrocarbon, as it may lead to aspiration.

3. A client with a diagnosis of Guillain-Barre syndrome is in a non-responsive state, yet vital signs are stable and breathing is independent. What should the nurse document to most accurately describe the client's condition?

• A. Comatose, breathing unlabored
• B. Glasgow Coma Scale 8, respirations regular
• C. Appears to be sleeping, vital signs stable
• D. Glasgow Coma Scale 13, no ventilator required

Correct answer: B

Rationale: The correct answer is B. A Glasgow Coma Scale of 8 with regular respirations accurately describes a non-responsive state with independent breathing. Choice A is incorrect because 'comatose' implies a deeper state of unconsciousness than what is described in the scenario. Choice C is inaccurate as the client is not merely sleeping but non-responsive. Choice D is incorrect as a Glasgow Coma Scale of 13 indicates a higher level of consciousness than what is presented in the scenario.

4. A nurse enters a client's room and finds her on the floor. The client's roommate reports that the client was trying to get out of bed and fell over the bedrail onto the floor. Which of the following statements should the nurse document about this incident?

• A. ''Incident report completed.''
• B. ''Client climbed over the bedrails.''
• C. ''Client found lying on the floor.''
• D. ''Client was trying to get out of bed.''

Correct answer: C

Rationale: The correct answer is C: ''Client found lying on the floor.'' In this situation, the nurse should document factual, objective information without making assumptions. Stating that the client was found lying on the floor directly reflects what was observed. Choice A, ''Incident report completed,'' is not a statement about the incident itself and does not provide relevant information. Choice B, ''Client climbed over the bedrails,'' introduces unnecessary speculation and assumption which should be avoided when documenting incidents. Choice D, ''Client was trying to get out of bed,'' focuses on the client's behavior rather than the objective observation of the client's position when found.

5. A nurse is preparing to administer methylprednisolone 10 mg by IV bolus. The amount available is methylprednisolone injection 40-mg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Do not use a trailing zero.)

• A. 0.3 mL
• B. 0.25 mL
• C. 0.4 mL
• D. 0.5 mL

Correct answer: A

Rationale: To calculate the mL to administer, use the formula: Dose required (mg) ÷ Stock concentration (mg/mL) = Volume to administer (mL). In this case, 10 mg ÷ 40 mg/mL = 0.25 mL. However, when rounding to the nearest tenth, the answer should be 0.3 mL. Therefore, the nurse should administer 0.3 mL. Choice A is the correct answer. Choice B (0.25 mL) is the result obtained before rounding. Choice C (0.4 mL) and Choice D (0.5 mL) are incorrect calculations.

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