Nursing Elites

1. What is the most important nursing action when a patient experiences a fall?

• A. Assess the patient for injuries
• B. Call for help
• C. Document the fall
• D. Notify the healthcare provider

Correct answer: A

Rationale: The most important nursing action when a patient experiences a fall is to assess the patient for injuries. This is critical to identify any potential harm or underlying issues that may require immediate attention. Calling for help and notifying the healthcare provider are important steps, but assessing the patient's condition takes precedence to ensure prompt and appropriate care. Documenting the fall is also necessary but should follow the initial assessment and care provided to the patient.

2. A nurse is teaching a newly licensed nurse about using a portable oxygen system. What instruction should the nurse include?

• A. The oxygen should be kept in a storage room when not in use.
• B. Turn off the oxygen when not in use.
• C. Check the oxygen level regularly using a pulse oximeter.
• D. Never leave the oxygen running when transporting a client.

Correct answer: C

Rationale: The correct answer is to check the oxygen level regularly using a pulse oximeter. This instruction is crucial as it ensures safe and adequate oxygenation for the client. Option A is incorrect as oxygen should not be stored in a storage room but in a well-ventilated area. Option B is not ideal as oxygen should be left on unless otherwise specified by a healthcare provider. Option D is also important but not directly related to the primary instruction of monitoring oxygen levels.

3. A nurse is preparing to administer an enema to a client. Which of the following actions should the nurse take?

• A. Place the client in a high-Fowler's position
• B. Assist the client to the left Sims' position
• C. Insert the enema tubing 2.5 cm (1 in) into the rectum
• D. Lubricate the tip of the enema tubing with petroleum jelly

Correct answer: B

Rationale: The correct answer is to assist the client to the left Sims' position when administering an enema. This position helps facilitate the flow of the enema solution into the rectum. Placing the client in a high-Fowler's position (Choice A) is not ideal for administering an enema. Inserting the enema tubing 2.5 cm (1 in) into the rectum (Choice C) is incorrect as it should be inserted 7.5-10 cm (3-4 in) for an adult. Lubricating the tip of the enema tubing with petroleum jelly (Choice D) is a correct step to ease insertion but is not the most critical action among the choices provided.

4. A client has a chest tube. Which of the following interventions should the nurse include?

• A. Clamp the chest tube for 15 minutes every 2 hours.
• B. Maintain the drainage system below the client's chest.
• C. Strip the chest tube every 2 hours.
• D. Keep the collection device at the level of the client's chest.

Correct answer: B

Rationale: Maintaining the chest tube drainage system below the client's chest level is crucial to ensure proper drainage and prevent complications. Clamping the chest tube can lead to a tension pneumothorax, stripping the chest tube is an outdated practice that can cause damage to the tissues, and keeping the collection device at the level of the client's chest can impede proper drainage and lead to fluid accumulation.

5. A nurse is caring for a client who has deep-vein thrombosis (DVT) and is receiving heparin therapy. Which of the following laboratory values indicates that the client's heparin therapy is effective?

• A. aPTT 75 seconds.
• B. INR 1.2.
• C. Hemoglobin 10 g/dL.
• D. Fibrinogen level 350 mg/dL.

Correct answer: A

Rationale: An aPTT of 75 seconds indicates that heparin therapy is within the therapeutic range for a client with DVT. The activated partial thromboplastin time (aPTT) is used to monitor heparin therapy's effectiveness. Choice B, INR 1.2, is not the correct answer because INR is used to monitor the effectiveness of warfarin, a different anticoagulant, not heparin. Choice C, Hemoglobin 10 g/dL, is not a measure of heparin therapy effectiveness. Choice D, Fibrinogen level 350 mg/dL, is not a specific indicator of heparin therapy effectiveness for DVT.

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