Nursing Elites

1. During the implementation phase of the nursing process when working with a hospitalized adult, which of the following actions would the nurse take?

• A. Formulate a nursing diagnosis of impaired gas exchange
• B. Record in the medical record the distance a client ambulates in the hall
• C. Write individualized nursing orders in the care plan
• D. Compare client responses to the desired outcomes for pain relief

Correct answer: B

Rationale: During the implementation phase of the nursing process, the nurse is responsible for carrying out or delegating nursing interventions and documenting nursing activities and client responses in the medical records. Option A involves diagnosing, which is part of the nursing process's earlier phases. Option C pertains to planning, which precedes implementation. Option D relates to evaluation, which comes after the implementation phase.

2. Which nursing intervention is most appropriate to reduce environmental stimuli that may cause discomfort for a client?

• A. Loosen pressure dressings on wounds
• B. Use assistance to lift a client in bed
• C. Check temperature of water used in a sponge bath
• D. Position the client in a prone position

Correct answer: C

Rationale: To reduce environmental stimuli that may cause discomfort for a client, nurses can implement various interventions. Checking the temperature of the water used in a sponge bath is crucial to prevent burns from water that is too hot or discomfort from water that is too cold. This intervention addresses a common source of discomfort for clients during personal care. Loosening pressure dressings on wounds, although important for wound care, does not directly address environmental stimuli. Using assistance to lift a client in bed is about proper positioning and preventing injury rather than reducing environmental stimuli. Positioning the client prone is not a suitable intervention for reducing discomfort caused by environmental stimuli.

3. What is the first aid for frostbite?

• A. Running cold water over the affected area. Warm or hot water will shock the area and cause more tissue damage.
• B. Run warm water over the area to rapidly rewarm the affected area.
• C. Run hot water over the area to warm the area as quickly as possible.
• D. Cover the area with a blanket, using a heating pad if the blanket isn't warm enough.

Correct answer: A

Rationale: First aid for frostbite involves running cold water over the affected area. It is important to avoid warm or hot water as it can shock the area and cause further tissue damage. Warm water should not be used to rapidly rewarm the affected area. Similarly, hot water should also be avoided as it can warm the area too quickly and potentially cause harm. Covering the area with a blanket and using a heating pad may not be effective and can even lead to more damage. Seeking medical assistance is crucial if the tissue appears necrotic to prevent further complications.

4. Which of the following sets of word parts means 'Pain'?

• A. dynia and -algia
• B. a- and an
• C. ia and -ac
• D. pathy and -osis

Correct answer: A

Rationale: The correct answer is 'dynia and -algia.' The word parts 'dynia' and '-algia' specifically relate to pain. 'Dynia' refers to pain, and '-algia' also denotes pain. Therefore, when combined, they form the meaning 'pain.' Choices B, C, and D are incorrect because 'a-' and 'an' do not relate to pain, 'ia' and '-ac' do not specifically convey pain, and 'pathy' and '-osis' are not word parts that directly signify pain.

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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