Nursing Elites

1. A nurse observes a colleague ignoring proper hand hygiene protocols. What should the nurse do first?

• A. Speak to the colleague directly.
• B. Ignore the situation, as it doesn't involve direct patient care.
• C. Report the colleague to the nursing manager.
• D. File an incident report immediately.

Correct answer: D

Rationale: The correct first action for the nurse to take in this situation is to file an incident report immediately. By doing so, the nurse ensures that the unsafe practice is documented for further investigation and corrective action. Speaking to the colleague directly may not address the root cause of the issue and could lead to potential conflicts. Ignoring the situation is not an appropriate response as it compromises patient safety. Reporting the colleague to the nursing manager should be done after filing an incident report to ensure that appropriate actions are taken to prevent future occurrences of non-compliance with hand hygiene protocols.

2. A client who is 97 years old has successfully been treated for heart failure and is found not breathing. There is no DNR order in place. What should the nurse do?

• A. Notify the family and await further instructions.
• B. Initiate CPR and call for emergency assistance.
• C. Allow the family to make decisions about care.
• D. Follow the family's wishes and perform no interventions.

Correct answer: B

Rationale: In this scenario, with no DNR order in place and the client not breathing, the nurse should initiate CPR and call for emergency assistance. Option A is incorrect as immediate action is required in the absence of breathing. Option C is incorrect as the nurse should act promptly to provide life-saving measures. Option D is incorrect because the nurse's primary duty is to provide care in the absence of a directive preventing intervention.

3. A nurse manager notices a discrepancy in a nurse's narcotics record. What is the appropriate action?

• A. Ask the nurse for clarification about the record.
• B. Report the discrepancy to the pharmacy.
• C. Report the issue to the nurse manager immediately.
• D. Ignore the discrepancy as a clerical error.

Correct answer: B

Rationale: The appropriate action when a nurse manager notices a discrepancy in a nurse's narcotics record is to report the discrepancy to the pharmacy. Reporting such discrepancies is crucial to ensure accountability and patient safety. Choice A is incorrect because the nurse manager should not confront the nurse directly without proper investigation. Choice C is incorrect because reporting to the nurse manager may not address the issue effectively. Choice D is incorrect because ignoring the discrepancy can compromise patient safety and violates protocols.

4. A nurse is assessing a client with diabetes who reports frequent episodes of hypoglycemia. What should the nurse recommend to prevent these episodes?

• A. Increase protein intake
• B. Monitor blood glucose levels frequently
• C. Increase the dose of insulin
• D. Reduce carbohydrate intake

Correct answer: B

Rationale: The correct recommendation to prevent hypoglycemic episodes in a client with diabetes who reports frequent episodes is to monitor blood glucose levels frequently. By monitoring blood glucose levels, the nurse can make necessary adjustments to insulin dosage and diet to maintain blood sugar levels within the target range. Increasing protein intake (Choice A) is not directly related to preventing hypoglycemia; it is more important to focus on balancing carbohydrates and insulin. Increasing the dose of insulin (Choice C) without proper monitoring can lead to further hypoglycemic episodes. Similarly, reducing carbohydrate intake (Choice D) should be done cautiously as carbohydrates are a main source of energy and sudden reduction can cause hypoglycemia in diabetic patients.

5. A nurse is preparing to discontinue a client's indwelling urinary catheter. Which of the following actions should the nurse take first?

• A. Measure and document the urine in the drainage bag
• B. Remove the tape or device securing the catheter to the client's thigh
• C. Position the client supine
• D. Deflate the catheter balloon using a sterile syringe

Correct answer: A

Rationale: The correct first action the nurse should take when discontinuing a client's indwelling urinary catheter is to measure and document the urine in the drainage bag. This step is essential to assess the client's urinary output and bladder function before removing the catheter. Removing the tape securing the catheter (Choice B) or positioning the client supine (Choice C) should come after measuring and documenting the urine output. Deflating the catheter balloon (Choice D) is the last step in the process of removing the catheter.

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