Nursing Elites

1. What should be included in the assessment of a client with a cast?

• A. capillary refill, warm toes, no discomfort.
• B. posterior tibial pulses, warm toes.
• C. moist skin essential, pain threshold.
• D. discomfort of the metacarpals.

Correct answer: A

Rationale: When assessing a client with a cast, it is crucial to check for capillary refill to ensure adequate circulation. Warm toes indicate good circulation, while the absence of discomfort suggests the cast is not causing any pain or undue pressure on the client. Therefore, choices B, C, and D are incorrect as they do not address the essential components of assessing a client with a cast.

2. An advance directive is written and notarized according to law in the state of Colorado. This document is legal and binding:

• A. internationally.
• B. in the state of Colorado only.
• C. in the continental United States.
• D. in the county of origination only.

Correct answer: B

Rationale: The correct answer is 'in the state of Colorado only.' Advance directive protocols and documents are specific to each state's laws and regulations. Choice A is incorrect as advance directives are not universally recognized internationally. Choice C is incorrect as the legal validity of an advance directive is limited to the state in which it was created. Choice D is incorrect as the legal reach of an advance directive typically extends throughout the state of origination, not just the county.

3. The nurse notes that a healthcare provider has documented the following prescription in a client's record: Furosemide (Lasix) 40 mg stat once. What action should the nurse take?

• A. Administering the medication
• B. Drawing up the medication in a syringe
• C. Planning to have the nurse on the next shift administer the medication
• D. Contacting the healthcare provider

Correct answer: D

Rationale: The correct action for the nurse to take in this situation is to contact the healthcare provider. The prescription provided lacks crucial information such as the route of administration. Before administering any medication, the nurse must clarify any missing details with the provider, especially for a stat prescription that requires immediate administration. Drawing up or administering the medication without verifying the route of administration is unsafe and can lead to errors. Planning for the next shift nurse to administer the medication is not appropriate in this scenario as the stat order necessitates immediate action. Therefore, the best course of action is to contact the healthcare provider to obtain clarification on the prescription.

4. Nail and foot care are essential in meeting the basic hygiene needs of clients. Important assessments by the nurse in this area include:

• A. a full-body assessment is not specific to nail and foot care.
• B. the essential lab work of the client is not related to nail and foot assessments.
• C. the nail beds and the tissue surrounding the nails.
• D. foot corns and calluses only neglect other important aspects of nail and foot care.

Correct answer: C

Rationale: The correct answer is to assess the nail beds and the tissue surrounding the nails. This assessment is crucial to identify abnormal discoloration, lesions, paronychia, dryness, breaks in the skin, pressure areas, or any other unusual appearances. Choice A is incorrect as a full-body assessment is broader and not specific to nail and foot care. Choice B is incorrect as lab work is not directly related to nail and foot assessments. Choice D is incorrect as it focuses only on foot corns and calluses, neglecting other important aspects of nail and foot care.

5. The nurse is teaching a client about sleep and gives background information on normal sleep patterns. Which of the following substances promotes sleep?

• A. serotonin
• B. cortisol
• C. alcohol
• D. narcotics

Correct answer: A

Rationale: Serotonin is a substance found in the body that promotes sleep. It plays a role in the synthesis of a hypnogenic factor that directly induces sleep. Cortisol is a stress hormone that can disrupt sleep patterns. Alcohol can disrupt REM sleep and negatively impact sleep quality. Narcotics, like alcohol, can interfere with sleep architecture and lead to poor quality sleep. Therefore, the correct answer is serotonin as it is associated with promoting sleep, while the other substances listed can have negative effects on sleep patterns.

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