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 preparing to perform a bladder scan for a client who has overflow incontinence. Which of the following actions should the nurse take?

• A. Place the client in a supine position.
• B. Obtain a prescription for insertion of an indwelling catheter.
• C. Cleanse the client's abdomen with an antiseptic solution.
• D. Prepare the client for urinary catheterization.

Correct answer: D

Rationale: The correct answer is to prepare the client for urinary catheterization. Overflow incontinence may indicate bladder distention, where a bladder scan helps assess the need for catheterization. Placing the client in a supine position (Choice A) is not directly related to the procedure. Obtaining a prescription for an indwelling catheter (Choice B) is not necessary before performing a bladder scan. Cleansing the client's abdomen with an antiseptic solution (Choice C) is not specific to preparing for a bladder scan in this situation.

3. A healthcare professional is caring for a client who has a new prescription for metformin. Which of the following laboratory results should the healthcare professional review before administering the medication?

• A. Potassium
• B. Serum creatinine
• C. Sodium
• D. Hemoglobin A1C

Correct answer: B

Rationale: Correct Answer: The healthcare professional should review serum creatinine levels before administering metformin to assess kidney function. Metformin is excreted by the kidneys, and checking serum creatinine helps prevent lactic acidosis, a potential side effect in individuals with impaired renal function. Choice A: Potassium levels are not directly related to the administration of metformin. While monitoring potassium levels is important for some medications, it is not the priority when initiating metformin. Choice C: Sodium levels are not typically assessed specifically before starting metformin. It is not a routine lab test required prior to metformin administration. Choice D: Hemoglobin A1C reflects long-term blood sugar control and is not a lab test that needs to be reviewed before initiating metformin. It is used to monitor diabetes management over time, not for immediate medication administration considerations.

4. A nurse is providing dietary teaching to a client who has chronic kidney disease. Which of the following foods should the nurse instruct the client to avoid?

• A. Apples.
• B. White bread.
• C. Bananas.
• D. Grapes.

Correct answer: C

Rationale: Bananas are high in potassium, which should be avoided by clients with chronic kidney disease to prevent hyperkalemia. Apples, white bread, and grapes do not have high potassium levels and are generally acceptable for clients with chronic kidney disease unless they have other specific dietary restrictions.

5. A nurse is assessing a newborn who is 12 hours old. Which of the following findings should the nurse report to the provider?

• A. Heart rate 140/min.
• B. A bulging anterior fontanel.
• C. Respiratory rate 50/min.
• D. Blood glucose 45 mg/dL.

Correct answer: D

Rationale: A blood glucose level of 45 mg/dL is below the normal range for a newborn and indicates hypoglycemia, which can lead to serious complications if left untreated. Therefore, this finding should be reported to the provider immediately. Choices A, B, and C are within normal ranges for a newborn and do not require immediate reporting. A heart rate of 140/min, a bulging anterior fontanel, and a respiratory rate of 50/min are all common findings in a newborn and do not raise immediate concerns.

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