Nursing Elites

1. A nurse suspects a colleague of diverting narcotics. What is the nurse's first course of action?

• A. Confront the colleague directly about the suspicion.
• B. Report the suspicion to the nurse manager.
• C. Ignore the situation unless there is clear evidence.
• D. Keep a record of the colleague's actions for future reference.

Correct answer: B

Rationale: The correct first course of action for a nurse suspecting a colleague of diverting narcotics is to report the suspicion to the nurse manager. Confronting the colleague directly may not be safe and could compromise the investigation. Ignoring the situation is not appropriate as it can pose risks to patient safety. Keeping a record of the colleague's actions is not the primary action to take when drug diversion is suspected; reporting to the nurse manager is crucial for proper investigation and ensuring patient safety.

2. A client complains of pain in their leg, and the nurse notes swelling and pallor. What is the priority nursing action?

• A. Administer pain medication.
• B. Elevate the limb and monitor closely.
• C. Encourage movement to reduce swelling.
• D. Notify the provider immediately about the symptoms.

Correct answer: D

Rationale: The correct answer is D: Notify the provider immediately about the symptoms. Swelling and pallor in a limb can be indicative of serious circulatory issues or compartment syndrome. It is crucial to inform the healthcare provider promptly to assess and address the situation. Administering pain medication (choice A) may temporarily alleviate the symptoms but does not address the underlying cause. Elevating the limb and monitoring closely (choice B) can be beneficial but does not replace the need for immediate professional evaluation. Encouraging movement to reduce swelling (choice C) is contraindicated in this scenario as it may worsen the condition if a circulatory issue or compartment syndrome is present.

3. The nurse is caring for a patient in restraints. Which essential information will the nurse document in the patient's medical record to provide safe care?

• A. Straps with quick-release buckles attached to bed side rails.
• B. Attempts to distract the patient with television are unsuccessful.
• C. Bilateral radial pulses present, 2+, hands warm to the touch.
• D. Released from restraints, active range-of-motion exercises completed.

Correct answer: C

Rationale: The correct answer is C because documenting bilateral radial pulses being present, 2+, and hands warm to the touch is crucial when caring for a patient in restraints. This information helps in monitoring circulation and assessing the patient's well-being. Choices A, B, and D are incorrect because they do not provide essential information related to the patient's safety and well-being while in restraints.

4. A nurse is preparing to administer a medication that requires a peak and trough level. What is the nurse's priority action?

• A. Administer the medication before the peak level is obtained.
• B. Withhold the medication until the trough level is obtained.
• C. Administer the medication based on the previous trough level.
• D. Ensure that the medication is administered within 2 hours of the peak level.

Correct answer: B

Rationale: The nurse's priority action should be to withhold the medication until the trough level is obtained. This is crucial to ensure accurate dosing based on the patient's levels. Administering the medication before the peak level is obtained (choice A) can lead to incorrect dosing. Administering the medication based on the previous trough level (choice C) may not reflect the current levels accurately. Ensuring that the medication is administered within 2 hours of the peak level (choice D) is not necessary for obtaining accurate peak and trough levels.

5. A nurse manager is planning client assignments for the day. Which client should the nurse assign to the nursing assistant?

• A. A client who needs help ambulating.
• B. A client who requires complex wound care.
• C. A client who needs intravenous antibiotics.
• D. A client who is NPO and requires IV hydration.

Correct answer: A

Rationale: The correct answer is A because ambulating a client is a non-invasive task that can be safely and effectively performed by a nursing assistant. Choice B is incorrect as complex wound care requires specialized skills usually performed by licensed nurses. Choice C involves administering intravenous antibiotics, which also requires a higher level of training and assessment skills than a nursing assistant possesses. Choice D, involving a client who is NPO and requires IV hydration, may involve further assessments and monitoring that are beyond the scope of a nursing assistant.

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