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 client with schizophrenia is beginning therapy with clozapine. Which statement indicates a need for further teaching?

• A. I will need to have my blood work checked regularly while taking clozapine.
• B. I understand that clozapine may cause me to gain weight.
• C. I should report any signs of a fever while taking clozapine.
• D. I should discontinue clozapine once my symptoms improve.

Correct answer: D

Rationale: The correct answer is D because clients should continue taking clozapine even if their symptoms improve. Abruptly discontinuing the medication can lead to relapse. Choices A, B, and C are all correct statements regarding clozapine therapy. Regular blood work monitoring is necessary due to potential side effects, weight gain is a common side effect of clozapine, and reporting signs of fever is important as it can indicate a serious side effect of clozapine.

3. A nurse is planning care for a client who has a stage 3 pressure injury. Which of the following interventions should the nurse include in the plan of care?

• A. Cleanse the wound with povidone-iodine solution daily.
• B. Irrigate the wound with hydrogen peroxide.
• C. Reposition the client every 4 hours.
• D. Use a moisture barrier ointment.

Correct answer: D

Rationale: The correct answer is to use a moisture barrier ointment. This intervention helps protect the skin and promote healing in clients with stage 3 pressure injuries. Cleansing the wound with povidone-iodine solution daily (Choice A) can be too harsh and may delay healing by damaging the surrounding skin. Irrigating the wound with hydrogen peroxide (Choice B) is not recommended as it can be cytotoxic to healing tissue. While repositioning the client every 4 hours (Choice C) is an essential intervention in preventing pressure injuries, it is not directly related to the care of an existing stage 3 pressure injury.

4. A client who is postoperative following a total hip arthroplasty is at risk for hip dislocation. Which of the following actions should the nurse take to prevent this complication?

• A. Position the client supine with a pillow between the legs
• B. Place a pillow under the client's knees
• C. Place an abduction pillow between the client's legs
• D. Place a trochanter roll under the client's legs

Correct answer: C

Rationale: After a total hip arthroplasty, it is crucial to prevent hip dislocation. Placing an abduction pillow between the client's legs helps maintain proper alignment and prevents the hip from dislocating. This position aids in keeping the hip in a neutral or slightly outwardly rotated position, reducing the risk of dislocation. Placing the client supine with a pillow between the legs (Choice A) or using a trochanter roll (Choice D) may not provide the same level of abduction and support needed to prevent hip dislocation. Placing a pillow under the client's knees (Choice B) does not provide the necessary support to maintain proper hip alignment in this situation.

5. A nurse working in a rehabilitation facility is developing a discharge plan for a client who has left-sided hemiplegia. Which of the following actions is the nurse's priority?

• A. Consult with a case manager regarding insurance coverage.
• B. Counsel caregivers on respite care options.
• C. Ensure that the client has a referral for physical therapy.
• D. Refer the client to a local stroke support group.

Correct answer: C

Rationale: The correct answer is C: 'Ensure that the client has a referral for physical therapy.' For a client with left-sided hemiplegia, physical therapy is crucial in restoring function and mobility. It is the nurse's priority to ensure the client receives the necessary rehabilitation services. Consulting with a case manager about insurance coverage (Choice A) is important but not the priority at this stage. Counseling caregivers on respite care options (Choice B) and referring the client to a local stroke support group (Choice D) are also valuable but not as essential as ensuring the client has access to physical therapy for rehabilitation.

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