Nursing Elites

1. At the beginning of the shift, a nurse receives report for her daily assignment. Which of the following situations should the nurse give first priority?

• A. A diabetic client with a blood glucose level of 195 mg/dL
• B. A family member of an elderly client who has questions
• C. A client with COPD with an oxygen saturation of 84%
• D. A client who requires assistance to use the bathroom

Correct answer: C

Rationale: When prioritizing the needs of clients, the nurse must begin with the unstable client or manage conditions that affect airway, breathing, or circulation first. The client with COPD has a condition that affects breathing and is exhibiting decreased oxygen saturation levels; therefore, this client should be the first priority. Option A, the diabetic client with a blood glucose level of 195 mg/dL, does not present an immediate threat to airway, breathing, or circulation. Option B, addressing questions from a family member, is important but can be addressed after addressing critical patient needs. Option D, assisting a client to use the bathroom, is a routine task that can be prioritized after addressing urgent medical needs.

2. What kind of preventive measures is MOST likely to be used to prevent Mary Eden from falling due to her muscular frailty?

• A. Physical therapy for muscle strengthening exercises
• B. Physical therapy for range of motion exercises
• C. Occupational therapy to help her with confusion
• D. Medications to help her sleep more

Correct answer: A

Rationale: Mary Eden, due to her muscular frailty, is at risk of falling. The most effective preventive measure in this case would be physical therapy focusing on muscle strengthening exercises. Strengthening exercises can help improve her muscle tone and stability, reducing the risk of falls. While range of motion exercises may be beneficial, they may not directly address her muscular frailty and stability concerns as effectively as muscle strengthening exercises. Occupational therapy aims to help individuals with activities of daily living and functional tasks, not confusion. Medications to induce more sleep can actually increase the risk of falls due to potential side effects like dizziness or disorientation, rather than preventing falls.

3. Is it true that Hepatitis C virus (HCV) can be spread through hugging, sneezing, coughing, sharing eating utensils, and other forms of casual contact?

• A. True
• B. False
• C.
• D.

Correct answer: B

Rationale: False. HCV is not spread through casual contact such as hugging, sneezing, or sharing eating utensils. The correct modes of transmission for HCV include direct contact with human blood through blood transfusions, improperly sterilized needles and syringes, needle sharing, or occasionally through sexual contact. Therefore, the statement is false, making 'False' the correct answer. Choices A, C, and D are incorrect as they do not accurately reflect the mode of transmission of HCV.

4. Which method is most appropriate for managing moral distress in the workplace?

• A. Recognizing that life is unfair and nurses cannot meet every need of every client
• B. Declining to act when clients or visitors make requests that are not justifiable
• C. Developing a new policy that would address the problematic situation
• D. Both A and B

Correct answer: C

Rationale: Moral distress involves negative feelings or frustration toward situations that are deemed unfair, unethical, or that cause the nurse to feel helpless in their work. It can lead to nurse burnout when ongoing issues are not resolved. The most appropriate method for managing moral distress is to develop new policies that address the problematic situations. By creating policies, nurses can work towards changing current standards and reducing the number of situations that lead to moral distress. Choices A and B are incorrect because recognizing life's unfairness and not taking action on unjustifiable requests do not actively address the root causes of moral distress or work towards resolving the issues.

5. A 23-year-old patient in the 27th week of pregnancy has been hospitalized on complete bed rest for 6 days. She experiences sudden shortness of breath, accompanied by chest pain. Which of the following conditions is the most likely cause of her symptoms?

• A. Myocardial infarction due to a history of atherosclerosis.
• B. Pulmonary embolism due to deep vein thrombosis (DVT).
• C. Anxiety attacks due to worries about her baby's health.
• D. Congestive heart failure due to fluid overload.

Correct answer: B

Rationale: In a hospitalized patient on prolonged bed rest, the most likely cause of sudden onset shortness of breath and chest pain is pulmonary embolism. Pregnancy and prolonged inactivity both increase the risk of clot formation in the deep veins of the legs, known as deep vein thrombosis (DVT). These clots can dislodge and travel to the lungs, causing a pulmonary embolism. Myocardial infarction (Choice A) is less likely in a young patient without a significant history of atherosclerosis. Anxiety attacks (Choice C) may present with similar symptoms but are less likely in this context. Congestive heart failure (Choice D) is less probable given the acute onset of symptoms and absence of typical signs like peripheral edema in this case.

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