Nursing Elites

1. The nurse is caring for a client who is dying. While assessing the client for signs of impending death, the nurse observes the client for:

• A. elevated blood pressure.
• B. Cheyne-Stokes respiration.
• C. elevated pulse rate.
• D. decreased temperature.

Correct answer: B

Rationale: Cheyne-Stokes respirations are a pattern of breathing characterized by rhythmic waxing and waning of respirations from very deep to very shallow breathing with periods of temporary apnea. This pattern is often associated with conditions like cardiac failure and can be a sign of impending death. Elevated blood pressure and pulse rate are not typically associated with the dying process. Decreased temperature is also not a common sign of impending death. Therefore, option B, Cheyne-Stokes respiration, is the correct choice when assessing a client for signs of impending death.

2. The physician has ordered sodium warfarin (Coumadin) for the client with thrombophlebitis. The order should be entered to administer the medication at:

• A. 900
• B. 1200
• C. 1700
• D. 2100

Correct answer: C

Rationale: Sodium warfarin is typically administered in the late afternoon, around 1700 hours. This timing allows for accurate bleeding times to be drawn in the morning. Administering it at 0900 (choice A) would not align with this schedule and may affect the monitoring of bleeding times. Choice B (1200) is midday, which is not the recommended time for sodium warfarin administration. Choice D (2100) is in the evening, which is also not ideal. Therefore, the correct time for administering sodium warfarin is 1700 (choice C).

3. While the client is receiving total parenteral nutrition (TPN), which lab test should be evaluated?

• A. Hemoglobin
• B. Creatinine
• C. Blood glucose
• D. White blood cell count

Correct answer: C

Rationale: When a client is receiving total parenteral nutrition (TPN), monitoring blood glucose levels is crucial as TPN solutions contain high amounts of glucose. This monitoring helps prevent hyperglycemia or hypoglycemia. Evaluating hemoglobin (choice A) is not directly related to TPN administration. Creatinine (choice B) is more relevant for assessing kidney function. White blood cell count (choice D) is important for evaluating immune function and infection, but not specifically tied to TPN administration.

4. When caring for African-American clients, what is an important consideration regarding their needs?

• A. Families may have specific needs.
• B. Special hair, skin, and nail care might be required.
• C. Cultural diets should be respected.
• D. Clients are generally future-oriented.

Correct answer: B

Rationale: Correct answer: Special hair, skin, and nail care might be required. African-American clients may have specific hair, skin, and nail care needs due to their unique characteristics such as curly hair and melanin-rich skin. It is important for healthcare providers to be knowledgeable about these needs to provide appropriate care. Option A is incorrect as it does not address the specific care aspect related to the clients themselves. Option C is incorrect as assuming all African-American clients follow cultural diets is a stereotype and may not apply to every individual. Option D is incorrect as being future-oriented is not a characteristic that is universally applicable to African-American clients and does not directly impact nursing care considerations.

5. The Token Economy is a type of therapy that focuses on:

• A. play therapy
• B. behavior modification
• C. milieu therapy
• D. associative

Correct answer: B

Rationale: The correct answer is 'behavior modification.' The Token Economy is a form of behavior modification that involves providing positive reinforcement in the form of tokens or rewards for desired behaviors. This approach aims to increase the occurrence of positive behaviors by rewarding them. Play therapy (choice A) focuses on using play as a medium for therapeutic communication, not specifically behavior modification. Milieu therapy (choice C) involves shaping the environment to promote desired behaviors but is not the primary focus of the Token Economy. 'Associative' (choice D) is not directly related to the Token Economy or its focus on behavior modification, making it an incorrect choice.

Similar Questions