Nursing Elites

1. A 54-year-old male client and his wife were informed this morning that he has terminal cancer. Which nursing intervention is likely to be most beneficial?

• A. Ask the wife how she would like to participate in the client's care
• B. Provide the wife with information about hospice
• C. Encourage the wife to visit after painful treatments are completed
• D. Refer the wife to a support group for family members of those dying of cancer

Correct answer: A

Rationale: The most beneficial nursing intervention in this situation is to ask the wife how she would like to participate in the client's care. Involving the spouse in the care of the terminally ill client can provide comfort, support, and a sense of contribution during a challenging time. Providing information about hospice (B) is important but may not be the immediate priority. Encouraging the wife to visit after treatments are completed (C) may delay her involvement in the care. Referring her to a support group (D) is a good idea but might be more suitable at a later stage.

2. A patient who had a transverse colectomy for diverticulosis 18 hours ago has nasogastric suction and is complaining of anxiety and incisional pain. The patient’s respiratory rate is 32 breaths/minute and the arterial blood gases (ABGs) indicate respiratory alkalosis. Which action should the nurse take first?

• A. Discontinue the nasogastric suction.
• B. Give the patient the PRN IV morphine sulfate 4 mg.
• C. Notify the health care provider about the ABG results.
• D. Teach the patient how to take slow, deep breaths when anxious.

Correct answer: B

Rationale: The patient’s respiratory alkalosis is caused by the increased respiratory rate associated with pain and anxiety. The nurse’s first action should be to medicate the patient for pain. Although the nasogastric suction may contribute to the alkalosis, it is not appropriate to discontinue the tube when the patient needs gastric suction. The health care provider may be notified about the ABGs but is likely to instruct the nurse to medicate for pain. The patient will not be able to take slow, deep breaths when experiencing pain.

3. While changing a client's post-operative dressing, the nurse observes a red and swollen wound with a moderate amount of yellow and green drainage and a foul odor. Given there is a positive MRSA, which is the most important action for the nurse to take?

• A. Force oral fluids
• B. Request a nutrition consult
• C. Initiate contact precautions
• D. Limit visitors to immediate family only

Correct answer: C

Rationale: The most important action for the nurse to take when a client has a positive MRSA and presents with a wound showing signs of infection is to initiate contact precautions. MRSA is highly contagious and placing the patient on contact precautions helps prevent the spread of the bacteria to others in the healthcare setting. (A) Forcing oral fluids will not directly address the MRSA infection. (B) Requesting a nutrition consult is not the priority in this situation. (D) Limiting visitors to immediate family only is not necessary as MRSA precautions are primarily focused on healthcare workers and close contacts who provide direct care.

4. A newly admitted patient is diagnosed with hyponatremia. When making room assignments, the charge nurse should take which action?

• A. Assign the patient to a room near the nurse’s station.
• B. Place the patient in a room nearest to the water fountain.
• C. Place the patient on telemetry to monitor for peaked T waves.
• D. Assign the patient to a semi-private room and place an order for a low-salt diet.

Correct answer: A

Rationale: The correct answer is A. The patient should be placed near the nurse’s station if confused to allow close monitoring by the staff. To help improve serum sodium levels, water intake is restricted, so a patient with hyponatremia should not be placed near a water fountain. Peaked T waves are a sign of hyperkalemia, not hyponatremia, so telemetry for this purpose is unnecessary. Placing a confused patient in a semi-private room could be disruptive to the other patient. Additionally, the patient needs sodium replacement, not a low-salt diet.

5. IV potassium chloride (KCl) 60 mEq is prescribed for the treatment of a patient with severe hypokalemia. Which action should the nurse take?

• A. Administer the KCl as a rapid IV bolus.
• B. Infuse the KCl at a rate of 10 mEq/hour.
• C. Only give the KCl through a central venous line.
• D. Discontinue cardiac monitoring during the infusion.

Correct answer: B

Rationale: The correct action for the nurse to take is to infuse the KCl at a rate of 10 mEq/hour. Rapid IV infusion of KCl can lead to cardiac arrest due to its potential for causing hyperkalemia. While KCl can be administered through peripheral veins, central venous lines are not necessary unless specified. It is crucial to continue cardiac monitoring during potassium infusion to promptly identify and manage any potential dysrhythmias that may occur.

Similar Questions