Nursing Elites

1. If a nurse administers an incorrect dose of medication, which fact related to the incident report should the nurse document in the client's medical record?

• A. Time the medication was given
• B. The client's response to the medication
• C. The dose that was administered
• D. Reason for the error

Correct answer: A

Rationale: The correct answer is to document the time the medication was given. This is essential for understanding the sequence of events surrounding the medication error. While documenting the client's response to the medication (Choice B) is important for assessing any effects, the immediate concern should be to establish a clear timeline by documenting the time of administration. Recording the dose administered (Choice C) is also important, but in the context of understanding the incident, the time factor takes precedence. The reason for the error (Choice D) should be included in the incident report but may not be the first priority when documenting in the client's medical record.

2. A nurse is reviewing the laboratory report of a client who has been receiving lithium carbonate for the past 12 months. The nurse notes a lithium level of 0.8 mEq/L. Which of the following orders from the provider should the nurse expect?

• A. Withhold the next dose.
• B. Increase the dosage.
• C. Discontinue the medication.
• D. Administer the medication.

Correct answer: D

Rationale: Administering the medication is appropriate for a stable lithium level of 0.8 mEq/L. A level of 0.8 mEq/L falls within the therapeutic range for lithium, indicating that the client is receiving an adequate dose to maintain therapeutic effects. Withholding the next dose, increasing the dosage, or discontinuing the medication would not be indicated at this lithium level as it is within the desired range for therapeutic benefit. Therefore, the correct action would be to continue administering the medication to ensure the client maintains the therapeutic level of lithium.

3. A client with diabetes mellitus is experiencing hypoglycemia. Which of the following findings should the nurse expect?

• A. Polyuria
• B. Warm, dry skin
• C. Irritability
• D. Hyperventilation

Correct answer: C

Rationale: Irritability is a common finding in clients with hypoglycemia due to decreased glucose levels in the brain. Polyuria (excessive urination) is not typically associated with hypoglycemia, but rather with hyperglycemia. Warm, dry skin is not a typical finding in hypoglycemia; instead, the skin may be cool and clammy. Hyperventilation is not a common finding in hypoglycemia; instead, shallow breathing or difficulty breathing may occur.

4. A nurse is preparing to insert an indwelling urinary catheter for a client. Which of the following actions should the nurse take?

• A. Insert the catheter 7.5 cm (3 in) into the urethra.
• B. Insert the catheter until urine flow is established.
• C. Cleanse the catheter with sterile water before insertion.
• D. Insert the catheter 5 cm (2 in) into the urethra.

Correct answer: B

Rationale: The correct action for the nurse is to insert the catheter until urine flow is established. This helps ensure proper placement and reduces the risk of trauma. Choice A (7.5 cm) and Choice D (5 cm) provide specific measurements that may not be appropriate for all individuals as catheter insertion depth can vary. Choice C is incorrect as catheters should be cleansed with an appropriate solution such as sterile saline, not sterile water.

5. A nurse is assessing a client who is 48 hours postoperative following a hip replacement. Which of the following findings should the nurse report to the provider?

• A. Heart rate 90/min.
• B. WBC count 15,000/mm3.
• C. Urinary output 75 mL in the past 4 hours.
• D. Temperature 37.8°C (100°F).

Correct answer: B

Rationale: An elevated WBC count 48 hours postoperatively may indicate an infection and should be reported to the provider. Choice A, a heart rate of 90/min, is within normal limits and not a concerning finding postoperatively. Choice C, urinary output of 75 mL in the past 4 hours, may indicate decreased renal perfusion, but an elevated WBC count is a more urgent finding. Choice D, a temperature of 37.8°C (100°F), which is slightly elevated, could be indicative of the body's normal response to surgery and is not as alarming as an elevated WBC count.

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