Nursing Elites

1. A nursing instructor asks a nursing student to describe accountability. Which statement(s) by the student indicate(s) an accurate description of accountability?

• A. Check the unit policy for the protocol for the care of clients who have been sexually assaulted.
• B. Ask a medical assistant.
• C. Call the nurse in charge of the day shift.
• D. Ask the police officers who brought the client to the center.

Correct answer: A

Rationale: Accountability in nursing involves taking responsibility for one's actions and decisions. In this scenario, checking the unit policy for the protocol related to the care of sexually assaulted clients demonstrates accountability. Policies and protocols provide guidance on appropriate actions and responsibilities in specific situations. Asking a medical assistant, calling the day shift nurse in charge, or consulting police officers are not appropriate actions to demonstrate accountability in this context. Seeking further clarification from the agency nursing supervisor on the night shift after reviewing the policy or protocol would be a more suitable course of action.

2. A nurse discharge planner is preparing a client for discharge from an acute care setting. The nurse assesses that skilled home care services are clinically indicated. This assessment is based on all of the following indicators except:

• A. the client has been admitted to the hospital three times in the last 2 months.
• B. the client has a Foley catheter.
• C. the client's family is available to care for him 24 hours a day.
• D. the client is ordered to continue IV antibiotics 5 days post discharge.

Correct answer: V

Rationale: Family availability to provide care and assistance is not an indicator for skilled home care services. In fact, the nurse might see an opportunity for family education to meet the client's needs so that less community support is needed. This should be discussed and negotiated with the family. Frequent hospital readmissions indicate that the client has not been able to manage either due to condition instability or lack of care needs being met, which is a red flag for home care services to monitor and meet those needs appropriately. A Foley catheter requires home health care due to infection potential and care requirements. IV antibiotics also necessitate home care for maintaining line patency and assessing the site.

3. An LPN is working on the care plan for a client with diabetes mellitus. Which of these outcomes would be the most appropriate?

• A. The client will maintain a blood glucose level within the normal range of 70-110 (per facility policy) throughout my shift.
• B. The client will maintain a blood glucose level within normal range limits today.
• C. The client will maintain a blood glucose level within the normal range of 70-110 (per facility policy) throughout my shift.
• D. The client will maintain a blood glucose level within normal limits throughout my shift.

Correct answer: C

Rationale: The correct answer is 'The client will maintain a blood glucose level within the normal range of 70-110 (per facility policy) throughout my shift.' This outcome is specific, measurable, and aligns with the goal of managing diabetes mellitus. Choice A is correct because it provides a clear target range (70-110) and includes adherence to facility policy, making it precise and goal-oriented. Choice B lacks specificity on the timeframe, and Choice D is vague in defining the target blood glucose range. In nursing care plans, outcomes should be well-defined, achievable, and measurable to effectively monitor the client's progress in managing their condition.

4. A nurse is watching as a new nurse employee administers an intramuscular (IM) injection in a client's deltoid muscle. The nurse determines that the new employee is performing the procedure correctly if the new employee uses which technique?

• A. Administers the injection 2 inches below the acromion process
• B. Positions the client with the deltoid muscle exposed
• C. Administers the injection in the thigh
• D. Places the client in the Sims position

Correct answer: A

Rationale: When administering an intramuscular injection in the deltoid muscle, the correct technique involves administering the injection 2 inches below the acromion process, which is the bony structure on top of the shoulder blade. This location ensures safe and effective administration. Administering the injection in the thigh (vastus lateralis or rectus femoris muscle) is not appropriate for a deltoid injection as the deltoid muscle is located in the upper arm. The Sims position is not the correct position for a deltoid muscle injection. While positioning the client with the deltoid muscle exposed allows for proper access and visualization, the critical aspect for a correct deltoid injection is the accurate injection site, 2 inches below the acromion process.

5. Which of the following nursing diagnoses is most appropriate for a client with a new colostomy?

• A. Excess Fluid Volume
• B. Risk for Aspiration
• C. Disturbed Body Image
• D. Urinary Retention

Correct answer: C

Rationale: Disturbed Body Image is the most appropriate nursing diagnosis for a client with a new colostomy. A new colostomy can significantly impact a person's body image and self-esteem due to the physical changes it brings. This can lead to emotional distress, adjustment issues, and concerns about body image. Excess Fluid Volume, Risk for Aspiration, and Urinary Retention are not directly related to the psychosocial impact of a new colostomy and are therefore not as relevant in this context. While Excess Fluid Volume, Risk for Aspiration, and Urinary Retention are important nursing diagnoses, they are not the priority when considering the psychological and emotional effects of a new colostomy.

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