Nursing Elites

1. The nurse is administering the 0900 medications to a client who was admitted during the night. Which client statement indicates that the nurse should further assess the medication order?

• A. At home I take my pills at 8:00 am.
• B. It costs a lot of money to buy all of these pills.
• C. I get so tired of taking pills every day.
• D. This is a new pill I have never taken before.

Correct answer: D

Rationale: The client's statement that 'This is a new pill I have never taken before' indicates the need for further assessment by the nurse to ensure the medication is correct and safe. Choices A, B, and C do not raise immediate concerns about the medication order; therefore, they are incorrect. Choice A simply provides information about the client's usual medication schedule, choice B is related to the cost of the pills, and choice C expresses fatigue from taking pills, but none of these statements suggest a potential issue with the new medication.

2. The healthcare provider plans to foster a therapeutic relationship with the patient utilizing therapeutic techniques of communication. It is most important that the provider:

• A. Work on establishing rapport with the patient.
• B. Use humor to lighten emotionally charged topics of discussion.
• C. Empathize with the patient when the patient shares sad feelings.
• D. Demonstrate respect when discussing emotionally charged topics.

Correct answer: D

Rationale: In fostering a therapeutic relationship, demonstrating respect is essential as it helps the patient feel valued and understood. Respectful communication contributes to building trust and a safe environment for open and honest discussions.

3. The nurse is preparing a client for surgery. What action is most important for the nurse to take?

• A. Ensure that the client signs the consent form.
• B. Review the client's allergies with the surgical team.
• C. Confirm the client's identity using two identifiers.
• D. Verify that the surgical site is marked.

Correct answer: A

Rationale: Ensuring that the client signs the consent form (A) is the most crucial action before surgery. The consent form is legally and ethically necessary for the procedure to proceed. While reviewing allergies (B), confirming identity (C), and verifying the surgical site (D) are essential steps, obtaining the client's informed consent takes precedence to protect the client's rights and ensure a safe surgical experience.

4. The healthcare provider identifies a potential for infection in a client with partial-thickness (second-degree) and full-thickness (third-degree) burns. What intervention has the highest priority in decreasing the client's risk of infection?

• A. Administration of plasma expanders
• B. Use of careful handwashing technique
• C. Application of a topical antibacterial cream
• D. Limiting visitors to the client with burns

Correct answer: B

Rationale: Proper handwashing technique is crucial in preventing the transmission of infections, especially in clients with burns where the risk of infection is high. It is the most effective intervention to reduce the risk of contamination and promote healing in these clients. While plasma expanders, topical antibacterial creams, and visitor restrictions are important considerations in burn care, meticulous hand hygiene takes precedence in preventing infections. Handwashing helps remove pathogens that could lead to infections, making it essential in the care of clients with burns.

5. When bathing an uncircumcised boy older than 3 years, which action should the nurse take?

• A. Remind the child to clean his genital area.
• B. Defer perineal care due to the child's age.
• C. Retract the foreskin gently to cleanse the penis.
• D. Inquire about the reason for the child not being circumcised.

Correct answer: C

Rationale: The correct action when bathing an uncircumcised boy older than 3 years is to gently retract the foreskin to cleanse the penis. This is important to ensure proper hygiene and prevent the accumulation of bacteria that can lead to infections. It is not advisable to defer perineal care because of the child's age, as hygiene is crucial at any age. Asking the parents about the circumcision status may not be relevant during routine perineal care. Reminding the child to clean his genital area is not as effective as directly cleaning the area during bathing.

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