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A nurse is teaching about sublingual nitroglycerin to a client who had a myocardial infarction. Which of the following information should the nurse include
Avoid eating or drinking until the medication is absorbed.
Keep the medication bottle in your pocket for easy access.
Do not take a second dose of the medication before 15 minutes has passed.
You can keep the medication tablets in a plastic, sorting container.
Correct Answer A. Avoid eating or drinking until the medication is absorbed.
Explanation
Sublingual nitroglycerin must dissolve under the tongue to be effective. Eating or drinking before it dissolves can wash it away and reduce absorption. The client should avoid food and fluids until the tablet is fully absorbed, usually in a few minutes.
Why Other Options Are Wrong
B. Keep the medication bottle in your pocket for easy access.
Keeping nitroglycerin in a warm or humid environment, like a pocket, can cause the medication to degrade. It should be stored in a cool, dry place in its original dark glass container.
C. Do not take a second dose of the medication before 15 minutes has passed.
This is incorrect. A second dose may be taken after 5 minutes if chest pain persists, up to three doses in 15 minutes, according to guidelines.
D. You can keep the medication tablets in a plastic, sorting container.
Nitroglycerin is sensitive to air, heat, and moisture. Storing it outside its original container, especially in plastic, can reduce its effectiveness. It must be kept in its original dark glass bottle.
A nurse is planning to form a quality improvement group to establish guidelines that attempt to reduce health care-associated infections in the facility. The nurse should identify which of the following as the first stage of group process that involves interprofessional collaboration
Norming
Storming
Forming
Performing
Correct Answer C. Forming
Explanation
The Forming stage is the first phase of group development. During this stage, team members are introduced, roles and responsibilities are clarified, and the group begins to understand the goals and purpose of their collaboration. It sets the foundation for successful teamwork and future progress in interprofessional collaboration.
Why Other Options Are Wrong
A. Norming
This is the third stage of group development, where team members begin to resolve differences, appreciate colleagues' strengths, and work more cohesively. It does not represent the initial stage.
B. Storming
This is the second stage and often involves conflict or competition as group members assert their ideas and challenge others. It comes after the team has formed.
D. Performing
This is the final stage where the group functions effectively toward achieving goals. It reflects maturity and productivity, not the beginning of the group process.
A nurse is performing triage tagging during a disaster drill. Which of the following disaster triage tags should the nurse apply to a client who has a fracture of the tibia with exposed bone and tissue
Nonurgent
Expectant
Urgent
Emergent
Correct Answer C. Urgent
Explanation
A client with a tibia fracture and exposed bone and tissue is experiencing a serious but not immediately life-threatening injury. This condition requires care within a few hours to prevent complications like infection or tissue necrosis but is not as critical as injuries that compromise airway, breathing, or circulation. Therefore, this client is tagged as Urgent (Yellow tag) in disaster triage.
Why Other Options Are Wrong
A. Nonurgent
This category (Green tag) is for minor injuries, such as abrasions or minor sprains. An open fracture is too severe for this classification.
B. Expectant
This category (Black tag) is used for clients who are not expected to survive, even with immediate intervention. A tibia fracture is treatable, so this does not apply.
D. Emergent
Emergent (Red tag) is reserved for life-threatening injuries requiring immediate intervention to survive (e.g., airway obstruction, major bleeding, shock). An open tibia fracture doesn’t meet that level of urgency.
A nurse is participating on a quality improvement committee to develop a plan to reduce medication errors at the facility. After formulating a proposed change in medication administration practice, which of the following steps should the committee take next
Review the proposed change against current medication administration guidelines
Evaluate the results of the change in medication administration practice
Develop a plan to analyze the data for the new administration practice
Implement the proposed change in the facility's medication administration guidelines
Correct Answer A. Review the proposed change against current medication administration guidelines
Explanation
After formulating a proposed change, the committee should review it against current medication administration guidelines and standards of practice to ensure it is evidence-based, safe, and aligns with regulatory and professional requirements. This validation step is essential before moving forward with implementation or data analysis.
Why Other Options Are Wrong
B. Evaluate the results of the change in medication administration practice
Evaluation happens after the change has been implemented and data have been collected. It is not the immediate next step after developing the proposal.
C. Develop a plan to analyze the data for the new administration practice
While planning for data analysis is important, it comes after confirming the proposal’s alignment with standards and before implementation.
D. Implement the proposed change in the facility's medication administration guidelines
Implementation should only occur after thoroughly reviewing the proposal against guidelines and preparing for monitoring and evaluation.
A nurse manager witnesses a nurse having a conflict with an assistive personnel (AP). Which of the following actions should the nurse manager take first
Provide training to recognize conflict resolution styles.
Clarify the role responsibilities with the nurse and AP.
Suggest using face-to-face communication to work out the conflict.
Identify the origin of the conflict to promote collaboration.
Correct Answer D. Identify the origin of the conflict to promote collaboration.
Explanation
The first step in managing a conflict is to identify its root cause. Understanding the origin helps the nurse manager determine the appropriate resolution strategy and guides effective communication between the individuals involved. Without this clarity, any attempt at resolution may be ineffective or misdirected.
Why Other Options Are Wrong
A. Provide training to recognize conflict resolution styles
Training is a long-term solution and not appropriate as a first response to an active conflict. It may be useful later to prevent future issues.
B. Clarify the role responsibilities with the nurse and AP
Clarifying roles may help if the conflict is due to role confusion, but the manager must first understand the source of the conflict before assuming the cause.
C. Suggest using face-to-face communication to work out the conflict
Encouraging direct communication is useful, but premature if the root cause has not been assessed. The conflict may involve deeper issues that need manager involvement.
A nurse is assessing a client who is 16 hr postoperative following a craniotomy for a brain tumor. Which of the following findings should the nurse report to the provider immediately
Periorbital ecchymosis
Urinary output of 280 mL over the past 8 hr
Rapid pupil reaction to light
Incisional drain output of 75 mL over the past 4 hr
Correct Answer A. Periorbital ecchymosis
Explanation
Periorbital ecchymosis following a craniotomy can indicate a basilar skull fracture or intracranial bleeding, both of which are serious complications. Although some swelling or bruising can occur from surgical manipulation, the sudden appearance or progression of bruising around the eyes—especially in the early postoperative period—requires immediate medical attention to rule out a cerebrospinal fluid (CSF) leak or intracranial hemorrhage.
Why Other Options Are Wrong
B. Urinary output of 280 mL over the past 8 hr
This value is slightly below expected output but not uncommon in the early postoperative period. It does not immediately indicate kidney failure or fluid imbalance unless it persists or worsens.
C. Rapid pupil reaction to light
This is a normal neurological finding and indicates intact cranial nerve III function. It is not concerning and does not require reporting.
D. Incisional drain output of 75 mL over the past 4 hr
This is within the expected range for post-craniotomy drainage. It becomes a concern if the drainage is excessive, suddenly increases, or changes in appearance.
A nurse manager is informed that a staff nurse has arrived for work chemically impaired. Which of the following actions is part of the responsibility of the nurse manager
Confront the nurse with an explanation of performance expectations.
Participate in the nurse's recovery process by providing direct care.
Plan to conduct a counseling session with the nurse on the following morning.
Determine why the nurse is using the chemically-impairing substance.
Correct Answer A. Confront the nurse with an explanation of performance expectations.
Explanation
The nurse manager has a legal and ethical responsibility to address impairment in the workplace immediately and directly. Confronting the nurse with professionalism while explaining performance expectations and safety concerns is appropriate. The priority is ensuring client safety, removing the impaired nurse from duty, and initiating reporting protocols as required by policy and regulatory bodies.
Why Other Options Are Wrong
B. Participate in the nurse's recovery process by providing direct care
The nurse manager’s role is administrative and supervisory, not clinical in this context. They should refer the nurse to appropriate assistance, not provide direct care.
C. Plan to conduct a counseling session with the nurse on the following morning
Delaying action poses a risk to client safety. The nurse manager must act immediately, not wait until the next day.
D. Determine why the nurse is using the chemically-impairing substance
Investigating personal motives is not within the immediate responsibilities of the nurse manager. The focus should be on ensuring safety and following reporting and referral procedures.
A nurse removes a fall hazard that is in an older adult client's path. The nurse should identify that this action is an example of which of the following ethical principles
Fidelity
Autonomy
Veracity
Nonmaleficence
Correct Answer D. Nonmaleficence
Explanation
Nonmaleficence is the ethical principle that refers to the duty to do no harm. By removing a fall hazard, the nurse is taking proactive steps to prevent injury, thereby fulfilling the obligation to protect the client from harm. This is a direct example of applying nonmaleficence in practice.
Why Other Options Are Wrong
A. Fidelity
Fidelity involves keeping promises and commitments to the client, such as following through with care or being trustworthy—not directly preventing harm.
B. Autonomy
Autonomy is the client's right to make their own decisions about care. Removing a fall hazard is about safety, not decision-making.
C. Veracity
Veracity refers to truth-telling and honesty in communication, not actions taken to prevent physical harm.
A nurse is creating a plan for quality improvement to reduce the incidence of health care-associated infections at an acute care facility. Which of the following actions should the nurse take first
Implement the plan in the health care setting.
Test the plan to see if refinements are needed.
Determine whether the plan will result in an improvement.
Adjust the plan as necessary to improve quality.
Correct Answer C. Determine whether the plan will result in an improvement.
Explanation
The first step in quality improvement is to evaluate whether the proposed plan has the potential to lead to measurable improvement. This involves reviewing current practices, setting goals, and ensuring the plan aligns with evidence-based strategies. Only after confirming its potential effectiveness should the plan move forward into testing and implementation.
Why Other Options Are Wrong
A. Implement the plan in the health care setting
Implementation should not occur before evaluating the plan’s potential effectiveness. Jumping to implementation too soon may waste resources.
B. Test the plan to see if refinements are needed
Testing comes after determining that the plan is likely to result in improvement. It is part of the Plan-Do-Study-Act (PDSA) cycle.
D. Adjust the plan as necessary to improve quality
This is a later step that follows testing and evaluation. Adjustments are made based on outcomes and feedback from earlier phases.
A nurse is assessing a client who has a deep-vein thrombosis and experiences a sudden onset of dyspnea. The nurse should identify that which of the following findings indicates the client is experiencing a pulmonary embolism
Xeroderma
Hiccups
Decreased heart rate
Pleural friction rub
Correct Answer D. Pleural friction rub
Explanation
A pleural friction rub is a classic sign of a pulmonary embolism (PE), especially when the embolism leads to pulmonary infarction. It results from inflammation of the pleura and occurs with pleuritic chest pain and dyspnea. The sudden onset of breathing difficulty along with this auscultatory finding strongly suggests PE in a client with DVT.
Why Other Options Are Wrong
A. Xeroderma
This refers to dry skin and is not related to pulmonary embolism. It is usually associated with dermatologic or autoimmune conditions.
B. Hiccups
Hiccups are not a typical symptom of pulmonary embolism. They may occur with gastrointestinal irritation or central nervous system issues, but not PE.
C. Decreased heart rate
Pulmonary embolism typically causes tachycardia (increased heart rate), not a decreased heart rate. The body responds to hypoxia and stress from the embolism with a sympathetic response.
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