Nursing Elites

1. A patient is kept off food and fluids for 10 hours before surgery. His oral temperature at 8 a.m. is 99.8°F (37.7°C). This temperature reading probably indicates:

• A. Infection
• B. Hypothermia
• C. Anxiety
• D. Dehydration

Correct answer: D

Rationale: A patient being kept off food and fluids before surgery can lead to dehydration. Dehydration can cause a slight increase in body temperature, which could explain the elevated oral temperature reading of 99.8°F (37.7°C) in this scenario. Infections are more likely to cause higher fevers, hypothermia would present with a lower temperature, and anxiety typically does not directly affect body temperature in this manner.

2. The healthcare provider orders the administration of an ampicillin capsule TID p.o. The healthcare provider should give the medication...

• A. Three times a day orally
• B. Three times a day after meals
• C. Two times a day by mouth
• D. Two times a day before meals

Correct answer: A

Rationale: In medical abbreviations, 'TID' stands for 'ter in die,' which means three times a day, and 'p.o.' stands for 'per os,' which means orally. Therefore, the correct administration schedule for the ampicillin capsule is three times a day orally. Choices B, C, and D are incorrect because they do not align with the prescribed frequency or route of administration specified in the order.

3. The client was asked to read the Snellen chart. Which of the following is being tested?

• A. Optic
• B. Olfactory
• C. Oculomotor
• D. Trochlear

Correct answer: A

Rationale: The correct answer is A: Optic. The Snellen chart is used to test visual acuity, which assesses the function of the optic nerve responsible for vision. Choices B, C, and D are incorrect. Olfactory relates to the sense of smell, oculomotor controls eye movement, and trochlear controls certain eye muscles. Therefore, the only option related to vision testing in this context is the optic nerve.

4. The physician orders a maintenance dose of 5,000 units of subcutaneous heparin (an anticoagulant) daily. Nursing responsibilities for Mrs. Mitchell now include:

• A. Reviewing daily activated partial thromboplastin time (APTT) and prothrombin time.
• B. Reporting an APTT above 45 seconds to the physician
• C. Assessing the patient for signs and symptoms of frank and occult bleeding
• D. All of the above

Correct answer: D

Rationale: The correct answer is D. When a physician orders a maintenance dose of subcutaneous heparin, nursing responsibilities include reviewing daily activated partial thromboplastin time (APTT) and prothrombin time to monitor the patient's coagulation status, reporting an APTT above 45 seconds to the physician as it may indicate a risk of bleeding, and assessing the patient for signs and symptoms of frank and occult bleeding, which are potential adverse effects of anticoagulant therapy. Therefore, all the options listed are essential nursing responsibilities when a patient is on subcutaneous heparin therapy.

5. A nurse is talking with another nurse on the unit and smells alcohol on her breath. Which of the following actions should the nurse take?

• A. Confront the nurse about the suspected alcohol use.
• B. Inform another nurse on the unit about the suspected alcohol use.
• C. Ask the nurse to finish administering medications and then go home.
• D. Notify the nursing manager about the suspected alcohol use.

Correct answer: A

Rationale: Confronting the nurse about the suspected alcohol use is the most appropriate action in this situation. It is essential to address the issue directly and express concerns about patient safety and potential impairment. By addressing the situation promptly, the nurse can potentially prevent harm and provide support to the colleague in need.

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