Nursing Elites

1. When planning home care for a 72-year-old client with osteomyelitis requiring a 6-week course of intravenous antibiotics, what is the most important action by the nurse?

• A. Investigating the client's insurance coverage for home IV antibiotic therapy
• B. Determining if there are adequate hand washing facilities in the home
• C. Assessing the client's ability to participate in self-care and/or the reliability of a caregiver
• D. Selecting the appropriate venous access device

Correct answer: C

Rationale: Assessing the client's ability to participate in self-care or evaluating the reliability of a caregiver is crucial in ensuring adherence to the treatment plan. This action helps determine if the client can manage the intravenous antibiotics at home independently or if assistance is needed. Investigating insurance coverage, ensuring hand washing facilities, and selecting the venous access device are important aspects of care but assessing the client's ability for self-care and caregiver reliability takes precedence to promote treatment success and safety.

2. A client is scheduled to have his alanine aminotransferase (ALT) level checked. The client asks the nurse to explain the laboratory test. Which of the following is an appropriate response by the nurse?

• A. “This test will indicate if you are at risk for developing blood clots.”
• B. “This test will determine if your heart is performing properly.”
• C. “This test will provide information about the function of your liver.”
• D. “This test is used to check how your kidneys are working.”

Correct answer: C

Rationale: The correct answer is C: “This test will provide information about the function of your liver.” Alanine aminotransferase (ALT) is an enzyme mainly found in the liver. An elevated ALT level may indicate liver damage or disease. Choices A, B, and D are incorrect because ALT is specifically related to liver function and not indicative of blood clot risk, heart performance, or kidney function.

3. A healthcare professional is caring for a group of clients on a medical-surgical unit. Which of the following clients is at increased risk for body-image disturbances?

• A. A client who had a laparoscopic appendectomy
• B. A client who had a mastectomy
• C. A client who had a left above-the-knee amputation
• D. A client who had a cardiac catheterization

Correct answer: C

Rationale: Clients who have undergone significant visible body changes, like amputation, are at increased risk for body-image disturbances. Amputation can have a profound impact on self-image and body perception due to the visible structural alteration. While conditions like laparoscopic appendectomy, mastectomy, and cardiac catheterization may also affect body image, they are less likely to cause significant disturbances compared to visible changes like amputation.

4. A client enters the emergency department unconscious via ambulance from the client's workplace. What document should be given priority to guide the direction of care for this client?

• A. The statement of client rights and the client self-determination act
• B. Orders written by the healthcare provider
• C. A notarized original copy of advance directives brought in by the partner
• D. The clinical pathway protocol of the agency and the emergency department

Correct answer: C

Rationale: In the scenario described, when a client arrives unconscious, priority should be given to a notarized original copy of advance directives brought in by the partner. Advance directives are legal documents that specify a person's healthcare wishes and decision-making preferences in advance. These directives guide healthcare providers in delivering care according to the client's preferences when the client is unable to communicate. The statement of client rights and the client self-determination act (Choice A) are important but do not provide specific care instructions. Orders written by the healthcare provider (Choice B) may not reflect the client's wishes. Clinical pathway protocols (Choice D) are valuable but do not address the individualized care preferences of the client.

5. A nurse is caring for a client who is postoperative and has signs of hemorrhagic shock. When the nurse notifies the surgeon, he directs her to continue to measure the client's vitals every 15 minutes and call him back in 1 hour. From a legal perspective, which of the following actions should the nurse take next?

• A. Notify the nursing manager.
• B. Document the client's condition and communication with the surgeon.
• C. Administer additional fluids as per standard procedure.
• D. Call the surgeon back immediately to ensure timely intervention.

Correct answer: B

Rationale: In this scenario, the nurse should choose option B, which is to document the client's condition and communication with the surgeon. By documenting the client's condition and the communication with the surgeon, the nurse ensures legal protection and maintains continuity of care. This documentation serves as evidence of the actions taken, communication exchanged, and the rationale behind decisions made. Option A, notifying the nursing manager, may not be necessary at this stage unless there are specific institutional protocols requiring it. Administering additional fluids without further clarification may not be appropriate and could worsen the client's condition if not indicated. Calling the surgeon back immediately (option D) may disrupt the agreed-upon plan of action and fail to follow the surgeon's instructions of reassessment after an hour.

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