Nursing Elites

1. The nurse is assigned to administer medications in a long-term care facility. A disoriented resident has no identification band or picture. What is the best nursing action for the nurse to take prior to administering the medications to this resident?

• A. Ask a regular staff member to confirm the resident's identity
• B. Hold the medication until a family member can confirm identity
• C. Re-orient the resident to name, place, and situation
• D. Confirm the room and bed numbers with those on the medication record

Correct answer: A

Rationale: In a long-term care facility, when a disoriented resident lacks identification, it is crucial to confirm the resident's identity before administering medication to prevent errors. Asking a regular staff member who is familiar with the resident to confirm their identity is the best course of action. This ensures accuracy and safety in medication administration. Holding the medication until a family member can confirm the identity could delay necessary treatment. Re-orienting the resident is important for their well-being but does not address the immediate medication safety concern. Confirming room and bed numbers, though important for administration logistics, does not verify the resident's identity.

2. An adult female client with type 1 diabetes mellitus is receiving NPH insulin 35 units in the morning. Which finding should the nurse document as evidence that the amount of insulin is inadequate?

• A. States that her feet are constantly cold and numb
• B. A wound on the ankle that starts to drain and becomes painful
• C. Consecutive evening serum glucose greater than 260 mg/dL
• D. Reports nausea in the morning but still able to eat breakfast

Correct answer: C

Rationale: The correct answer is C. Consistently high evening glucose levels indicate that the current insulin dosage is inadequate to maintain proper glucose control. Choice A is incorrect because cold and numb feet are more indicative of peripheral vascular disease rather than inadequate insulin dosage. Choice B describes a wound that may be related to poor circulation or neuropathy but not necessarily inadequate insulin dosage. Choice D suggests gastrointestinal issues that are not directly related to insulin dosage adequacy.

3. In which stage of Maslow's hierarchy of needs is a young adult attempting to achieve when deciding to change his work hours to devote more time to his community?

• A. Self-Actualization
• B. Intimacy vs. Isolation
• C. Altruism
• D. Purposefulness

Correct answer: A

Rationale: The correct answer is A: Self-Actualization. The young adult is striving for self-actualization, the highest level in Maslow's hierarchy of needs. Self-actualization is characterized by individuals seeking personal growth, self-fulfillment, and the ability to contribute to society. Choice B, Intimacy vs. Isolation, focuses on relationships and occurs at a different stage. Choice C, Altruism, although related to community contribution, does not specifically address personal growth and fulfillment as in self-actualization. Choice D, Purposefulness, is not a stage in Maslow's hierarchy of needs and is not directly relevant to the scenario described.

4. Based on the principle of asepsis, which situation should the nurse consider to be sterile?

• A. A one-inch border around the edges of a sterile field set up in the operating room
• B. A sterile glove that the nurse thinks might have touched her hair
• C. A wrapped, unopened sterile 4x4 gauze pad placed on a damp tabletop
• D. An open sterile Foley catheter kit set up on a table at the nurse's waist level

Correct answer: D

Rationale: The correct answer is D because an open sterile Foley catheter kit set up at waist level is considered sterile if it has not been contaminated. Choice A is incorrect because the one-inch border around a sterile field is considered non-sterile. Choice B is incorrect because a sterile glove that might have touched the nurse's hair is likely contaminated. Choice C is incorrect because a wrapped, unopened sterile gauze pad placed on a damp tabletop may have become contaminated.

5. A client with blood type AB negative delivers a newborn with blood type A positive. The cord blood reveals a positive indirect Coombs test. Which is the implication of this finding?

• A. The newborn is infected with an infectious blood-borne disease
• B. The newborn needs phototherapy for physiologic jaundice
• C. The mother's Rh antibodies are present in the neonatal blood
• D. The mother no longer needs Rho immune globulin injections

Correct answer: C

Rationale: A positive indirect Coombs test indicates that the mother's Rh antibodies have crossed the placenta and are present in the neonatal blood, which can lead to hemolytic disease of the newborn. This finding necessitates close monitoring and potential intervention. Choice A is incorrect because a positive Coombs test does not indicate an infectious blood-borne disease. Choice B is incorrect as phototherapy for physiologic jaundice is not related to a positive Coombs test result. Choice D is incorrect because a positive Coombs test does not indicate that the mother no longer needs Rho immune globulin injections; in fact, it suggests a need for further management to prevent hemolytic disease of the newborn.

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