Nursing Elites

1. The nurse is preparing to administer medications to a client with a nasogastric tube. Which action should the nurse take first?

• A. Check for tube placement
• B. Crush the medications
• C. Flush the tube with water
• D. Administer the medications

Correct answer: A

Rationale: The correct first action when administering medications to a client with a nasogastric tube is to check for tube placement. This is crucial to ensure that the medications are delivered to the correct location within the gastrointestinal tract. Checking the tube placement helps prevent complications such as medication entering the lungs if the tube is misplaced. Crushing the medications (choice B) or flushing the tube with water (choice C) should only be done after confirming the correct tube placement. Administering the medications (choice D) without verifying the tube placement can lead to serious consequences.

2. A client diagnosed with tuberculosis (TB) is placed on drug therapy with rifampin (Rifadin). The client should be instructed to report which effect(s) of the medication to the healthcare provider?

• A. Reddish-orange discoloration of body fluids
• B. Bloody or blood-tinged urine
• C. Blurring of vision
• D. Weight gain of more than 2 pounds in a week

Correct answer: A

Rationale: The correct answer is A. Rifampin (Rifadin) commonly causes a reddish-orange discoloration of body fluids, including urine, sweat, saliva, and tears. This is a harmless side effect but should be reported to the healthcare provider for monitoring. Choices B, C, and D are not typically associated with rifampin therapy. Bloody or blood-tinged urine may indicate other issues such as urinary tract infection or kidney problems, blurring of vision may suggest eye problems, and significant weight gain could be related to various health conditions unrelated to rifampin.

3. Nurses working in labor and delivery are demanding a change in policy because they believe they are required to float more often than nurses on other units. However, floating to labor and delivery is not reciprocated because other nurses are not competent to provide highly specialized obstetrical skills. What action is best for the nurse-manager to implement?

• A. Require cross-training for obstetrics for other nurses
• B. Propose a method for self-staffing labor and delivery
• C. Remind nurses that floating is an administrative policy
• D. Encourage nurses to share their feelings with administration

Correct answer: B

Rationale: The best action for the nurse-manager to implement is to propose a method for self-staffing labor and delivery. This approach allows nurses to manage their schedules, ensuring a fair balance of workloads. Requiring cross-training for obstetrics for other nurses (Choice A) may not be feasible or necessary for all units. Reminding nurses that floating is an administrative policy (Choice C) does not address the underlying issue of workload balance. Encouraging nurses to share their feelings with administration (Choice D) may not lead to a concrete solution for the unequal floating concerns.

4. When preparing an educational program for adolescents about the risks of multiple sexual partners, which information is most important to include?

• A. Condoms provide reliable protection against sexually transmitted infections.
• B. Having multiple sexual partners increases the risk of contracting sexually transmitted infections.
• C. The use of oral contraceptives can reduce the risk of sexually transmitted infections.
• D. Having multiple sexual partners increases the risk of developing cancer.

Correct answer: B

Rationale: The correct answer is B because having multiple sexual partners significantly increases the risk of contracting sexually transmitted infections (STIs). This information is crucial for adolescents to understand the potential consequences of engaging in risky sexual behaviors. Choice A is incorrect because while condoms are important for protection, they are not 100% effective. Choice C is incorrect as oral contraceptives do not protect against STIs. Choice D is incorrect as the immediate concern for adolescents in this context is the risk of STIs rather than cancer.

5. The nurse observes a client in a wheelchair with a vest restraint in place. What nursing intervention is most important for the nurse to implement?

• A. Assess the need for continued restraint
• B. Check the client for urinary incontinence
• C. Determine skin integrity under the vest
• D. Perform range-of-motion exercises on extremities

Correct answer: A

Rationale: The correct answer is to assess the need for continued restraint. This is the most important nursing intervention as it ensures the client's safety and autonomy. Checking for urinary incontinence (Choice B) may be important but is not the priority in this situation. Determining skin integrity under the vest (Choice C) is essential but not as crucial as assessing the need for continued restraint. Performing range-of-motion exercises (Choice D) is important for client mobility but not the priority when a restraint is in place.

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