Nursing Elites

1. The patient experienced a surgical procedure, and Betadine was utilized as the surgical prep. Two days postoperatively, the nurse's assessment indicates that the incision is red and has a small amount of purulent drainage. The patient reports tenderness at the incision site. The patient's temperature is 100.5°F, and the WBC is 10,500/mm³. Which action should the nurse take first?

• A. Reevaluate the temperature and white blood cell count in 4 hours.
• B. Check which solution was used for skin preparation in surgery.
• C. Plan to change the surgical dressing during the shift.
• D. Utilize SBAR to notify the primary health care provider.

Correct answer: D

Rationale: The patient is showing signs of a possible surgical site infection, including redness, purulent drainage, tenderness, elevated temperature, and increased white blood cell count. These symptoms suggest the need for immediate action to address a potential complication. Utilizing SBAR to notify the primary health care provider is crucial as it allows for effective communication of the patient's condition and the need for further assessment and intervention. Reevaluating the temperature and white blood cell count later, checking the solution used for skin preparation, or planning to change the dressing do not address the urgent need for intervention and communication with the healthcare provider.

2. A nurse enters a client's room and finds the client pulseless. The client's living will requests no resuscitation be performed, but the provider has not written the prescription. Which of the following actions should the nurse take?

• A. Administer emergency medications without performing CPR
• B. Begin CPR
• C. Call the provider for a do-not-resuscitate (DNR) order
• D. Respect the client's wishes, and do not attempt CPR

Correct answer: B

Rationale: The correct action for the nurse to take in this situation is to begin CPR. In the absence of a written DNR order by the provider, the nurse is ethically and legally obligated to initiate CPR to attempt to save the client's life. Administering emergency medications without CPR (Choice A) may not address the immediate need for life-saving measures. Calling the provider for a DNR order (Choice C) may cause a delay in providing necessary resuscitative measures. Respecting the client's wishes and not attempting CPR (Choice D) goes against the nurse's duty to provide immediate life-saving interventions in the absence of a DNR order.

3. A nurse is caring for a client and realizes they have administered the wrong medication. Which of the following actions should the nurse take first?

• A. Notify the provider
• B. Check the condition of the client
• C. Document the occurrence in the electronic medical record
• D. Complete an incident report

Correct answer: B

Rationale: The correct answer is to 'Check the condition of the client' first. When a medication error occurs, the nurse's initial priority should be to assess the client's condition to address any immediate harm or side effects. Notifying the provider can come after ensuring the client's safety. Documenting the occurrence in the electronic medical record and completing an incident report are important steps but should follow the assessment of the client's condition to prioritize patient safety.

4. When a nurse is assigned to float to another unit and feels unprepared, what is the most appropriate course of action?

• A. Refusing to take the assignment.
• B. Requesting help and clarification from the charge nurse.
• C. Completing the assignment and documenting the concerns later.
• D. Filing a formal complaint with hospital administration.

Correct answer: B

Rationale: When a nurse is assigned to float to another unit and feels unprepared, the most appropriate course of action is to request help and clarification from the charge nurse. This allows the nurse to address any concerns, seek guidance, and ensure safe patient care. Refusing the assignment (Choice A) is not a constructive approach as it may leave the unit short-staffed and compromise patient safety. Completing the assignment and documenting concerns later (Choice C) is not recommended as it delays addressing the issues at hand. Filing a formal complaint with hospital administration (Choice D) should be considered only after attempting to resolve the issue at the unit level first.

5. A nurse is observing a nursing student practicing standard precautions. Which observation by the instructor indicates that further teaching is necessary?

• A. The nursing student wears gloves when changing bed linens.
• B. The nursing student wears gloves to remove a wound dressing.
• C. The nursing student washes hands after removing gloves.
• D. The nursing student touches the patient's skin with sterile gloves.

Correct answer: D

Rationale: The correct answer is D because touching a patient's skin with sterile gloves compromises the sterility of the gloves, increasing the risk of contamination. Choices A, B, and C demonstrate correct practices in standard precautions. Wearing gloves when changing bed linens and to remove a wound dressing, as well as washing hands after removing gloves, are all appropriate and necessary steps to prevent the spread of infection.

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