Nursing Elites

1. Before allowing the client's infant granddaughter to visit before the client's scheduled heart transplant, the nurse decides it would be beneficial to collaborate with which of the following? Select all that apply.

• A. Client and Family
• B. Other nursing staff on the unit
• C. Security department
• D. Hospital administration

Correct answer: B

Rationale: Collaborating with the client and family is crucial as it fosters a sense of autonomy and active involvement in the healthcare process for the client. Involving other nursing staff ensures the successful implementation of the planned intervention and provides support for the client's needs. Collaboration with the security department or hospital administration is not necessary in this situation, as the focus should be on the client's well-being and family involvement during a sensitive time.

2. A client is post-op day #1 after a hemilaminectomy. The nurse removes the dressing as ordered and notes that the incision appears slightly red, with a small amount of serous drainage coming from the site. The edges of the incision are approximated. What is the next action of the nurse?

• A. Assist the client to shower as ordered and monitor the site for further changes
• B. Instruct the client to lie prone to allow the site to dry
• C. Place antibiotic ointment and a sterile dressing over the site
• D. Notify the physician for an antibiotic order

Correct answer: A

Rationale: An incision that appears slightly red with a small amount of serous drainage on the first day following surgery is going through a normal healing process. It is important to keep the incision clean. In this case, the nurse should assist the client to shower as ordered to maintain hygiene and monitor for changes in the incision site. Instructing the client to lie prone may not be necessary and could cause discomfort. Applying antibiotic ointment without a specific order is not recommended as it can interfere with the healing process. Notifying the physician for an antibiotic order is premature at this stage since the incision is showing normal signs of healing.

3. Which of the following scenarios provides an example of a healthcare professional overcoming a barrier to communication?

• A. A healthcare professional uses a visual aid to explain how to conduct a fingerstick glucose test to a patient with visual impairment.
• B. A healthcare professional writes down instructions for a patient who is hearing impaired.
• C. A healthcare professional raises their voice when speaking to a patient who does not speak English.
• D. A healthcare professional uses medical jargon while conversing with a minor.

Correct answer: B

Rationale: Overcoming barriers to communication in healthcare involves utilizing methods of communication that are accessible and understandable to the recipient. In the scenario provided, writing down instructions for a patient who is hearing impaired is an effective way to ensure clear communication and overcome the obstacle of hearing impairment. This method allows the patient to visually comprehend the information provided. Choice A is incorrect because using a visual aid for a visually impaired patient, not a hearing-impaired patient, would be more appropriate. Choice C is incorrect as raising one's voice does not address the language barrier effectively and may not enhance understanding. Choice D is incorrect as using complex medical terms with a minor may lead to confusion and hinder effective communication.

4. A physician has ordered that a client must be placed in a high Fowler's position. How does the nurse position this client?

• A. The client is placed face-down
• B. The client lies on his back with his head lower than his feet
• C. The client lies on his back with the knees drawn up toward the chest
• D. The client is sitting with the backrest at a 90-degree angle

Correct answer: D

Rationale: A high Fowler's position is a modification of the semi-Fowler's position, in which the client is seated with arms resting at the sides or in the lap. The high Fowler's position requires that the client's head and upper chest are elevated, and the backrest is at a 90-degree angle. This position supports breathing and appropriate chest wall movement, making it easier for the client to breathe. Choices A, B, and C are incorrect because a high Fowler's position involves the client being in a sitting position with the backrest at a 90-degree angle, not being face-down, lying with the head lower than the feet, or lying on the back with knees drawn up towards the chest.

5. A nurse is completing an incident report about a medication error that she made when she accidentally administered too much insulin to a diabetic client. All of the following are components of this documentation EXCEPT:

• A. The reason for administering the wrong dose
• B. The type of drug involved
• C. The amount of insulin that was given
• D. Any adverse effects on the client

Correct answer: A

Rationale: When completing an incident report for a medication error, it is essential to include factual information such as the type of drug involved, the amount administered, and any adverse effects on the client. However, stating the reason for administering the wrong dose should be avoided in documentation. The focus should be on reporting what happened rather than assigning blame or admitting fault. This approach helps in ensuring a thorough and accurate account of the medication error without introducing subjective elements that could complicate the investigation or resolution process. Therefore, the correct answer is 'The reason for administering the wrong dose.' Choices A, B, and D are vital components of incident report documentation, providing crucial details that help in understanding the error and its impact on the client.

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