Nursing Elites

1. The nurse enters a male client's room to administer routine morning medications, and the client is on the phone. Which action is best for the nurse to take?

• A. Ask another nurse to return with the medication when the client has hung up the phone
• B. Wait for the client to excuse himself from the telephone conversation, and observe the client taking the medication
• C. Return the medication to the client's drawer on the cart and document that the client refused the dose
• D. Leave the medication with the client and let him take it when he finishes the conversation

Correct answer: B

Rationale: The best action for the nurse to take in this situation is to wait for the client to excuse himself from the telephone conversation and then observe the client taking the medication. This approach ensures that the client takes the medication as prescribed, promoting compliance and safety. Choice A is not ideal as it involves unnecessary delegation and may lead to confusion. Choice C is incorrect because assuming refusal without direct communication can compromise patient care. Choice D is not recommended as leaving the medication with the client unsupervised may result in non-compliance or potential errors.

2. The nurse determines that a client with cirrhosis is experiencing peripheral neuropathy. What action should the nurse take?

• A. Protect the client's feet from injury
• B. Apply a heating pad to affected area
• C. Keep the client's feet elevated
• D. Assess the feet and legs for jaundice

Correct answer: A

Rationale: Protecting the client's feet from injury is essential when managing peripheral neuropathy in a client with cirrhosis. Peripheral neuropathy can result in reduced sensation, increasing the risk of injury. Applying a heating pad or keeping the client's feet elevated would not address the primary concern of preventing injury. Assessing the feet and legs for jaundice is important for monitoring liver function, but it is not directly related to managing peripheral neuropathy in this case.

3. All of the following are posture and body alignment problems EXCEPT:

• A. Kyphosis
• B. Scoliosis
• C. Thrombosis
• D. Lumbar lordosis

Correct answer: C

Rationale: Thrombosis is a condition involving blood clots and is not related to posture or body alignment, unlike kyphosis, scoliosis, and lumbar lordosis, which are spinal alignment issues. Kyphosis refers to excessive outward curvature of the spine, scoliosis is characterized by a sideways curvature of the spine, and lumbar lordosis involves an exaggerated inward curve in the lower back. Thrombosis, on the other hand, is a condition where blood clots form in the blood vessels, not a posture or body alignment problem.

4. A client who is post-operative from a bowel resection is experiencing abdominal distention and pain. The nurse notices the client has not passed gas or had a bowel movement. What should the nurse assess first?

• A. The client's bowel sounds.
• B. The client's fluid intake.
• C. The client's pain level.
• D. The client's surgical incision.

Correct answer: A

Rationale: Assessing bowel sounds is crucial in this situation as it helps determine if the client's gastrointestinal tract is functioning properly. Absent or hypoactive bowel sounds can indicate an ileus, a common post-operative complication. Assessing fluid intake (Choice B) is important but should come after assessing bowel sounds. Pain assessment (Choice C) is essential but addressing the physiological issue should take precedence. Checking the surgical incision (Choice D) is relevant but not the priority when the client is experiencing abdominal distention and potential gastrointestinal complications.

5. Which is the most important safety measure when administering a medication through a patient’s central venous catheter (CVC)?

• A. Using a sterile technique
• B. Ensuring correct placement of the CVC
• C. Flushing the CVC with saline after administration
• D. Monitoring for signs of infection

Correct answer: B

Rationale: The most important safety measure when administering a medication through a patient’s central venous catheter (CVC) is ensuring the correct placement of the CVC. This is crucial to prevent complications such as extravasation, infection, or improper drug delivery. While using a sterile technique, flushing the CVC with saline after administration, and monitoring for signs of infection are all important aspects of CVC care, ensuring the correct placement of the catheter takes precedence as it directly impacts patient safety during medication administration.

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