Nursing Elites

1. A client asks the nurse to call the police and states: 'I need to report that I am being abused by a nurse.' The nurse should first

• A. Focus on reality orientation to place and person
• B. Assist with the report of the client's complaint to the police
• C. Obtain more details of the client's claim of abuse
• D. Document the statement in the client's chart with a report to the manager

Correct answer: C

Rationale: The correct initial action for the nurse is to obtain more details about the client's claim of abuse. This will help the nurse better understand the situation before proceeding with any further actions. Option A is incorrect as reality orientation is not the priority in this situation. Option B is premature as more details are needed first. Option D is not the immediate step as gathering information should come before documentation and reporting.

2. A male client with HIV receiving saquinavir PO in combination with other antiretrovirals reports constant hunger and thirst but is losing weight. What action should the nurse implement?

• A. Use a glucometer to check glucose level.
• B. Teach client to measure weight accurately.
• C. Explain that medication dose may need to be increased.
• D. Reassure client weight will increase as viral load decreases.

Correct answer: A

Rationale: The correct action for the nurse to implement is to use a glucometer to check the client's glucose level. Saquinavir, an HIV medication, can lead to hyperglycemia, which may cause symptoms like constant hunger and thirst while losing weight. Checking the glucose level will help assess for hyperglycemia. Choice B is not the priority in this situation as the client's weight loss is a concerning symptom that needs immediate attention. Choice C is incorrect because increasing the medication dose without assessing the glucose level first could exacerbate hyperglycemia. Choice D is incorrect as it does not address the symptoms of constant hunger, thirst, and weight loss, which may indicate a more urgent issue like hyperglycemia.

3. A client is diagnosed with Meniere's disease. Which problem should the nurse identify as most important in the plan of care?

• A. Social isolation related to hearing loss
• B. Risk for injury related to vertigo
• C. Impaired verbal communication
• D. Impaired hearing related to ear disease

Correct answer: B

Rationale: Vertigo is the primary symptom of Meniere's disease and can lead to falls and other injuries. Ensuring safety and addressing the risk of injury is the nurse's top priority. While social isolation and impaired hearing are significant concerns associated with Meniere's disease, the immediate danger of falls due to vertigo takes precedence in the plan of care. Impaired verbal communication, although important, is not as urgent as preventing injuries caused by vertigo.

4. An older client with SIRS has a temperature of 101.8°F, a heart rate of 110 beats per minute, and a respiratory rate of 24 breaths per minute. Which additional finding is most important to report to the healthcare provider?

• A. Serum creatinine of 2.0 mg/dL
• B. Elevated WBC count
• C. Blood pressure of 100/60 mmHg
• D. Oxygen saturation of 95%

Correct answer: A

Rationale: A serum creatinine level of 2.0 mg/dL indicates possible acute kidney injury, which can occur during severe systemic inflammatory response syndrome (SIRS). Reporting this value promptly allows for interventions to prevent further renal damage. Elevated WBC count (choice B) is a common feature of SIRS and may not be as urgently indicative of immediate organ damage as high creatinine levels. A blood pressure of 100/60 mmHg (choice C) is relatively low but may be a typical finding in SIRS; however, renal function is critical in this context. Oxygen saturation of 95% (choice D) is within normal limits and is not as concerning as a high creatinine level in this scenario.

5. A client is admitted with pneumonia and is started on antibiotics. After 3 days, the client reports difficulty breathing and a rash. What is the nurse's first action?

• A. Administer epinephrine
• B. Discontinue the antibiotic
• C. Assess the client's oxygen saturation
• D. Call the healthcare provider

Correct answer: B

Rationale: The client's difficulty breathing and rash suggest a possible allergic reaction to the antibiotic. The first action the nurse should take is to discontinue the antibiotic to prevent further exposure. Administering epinephrine should only be done in severe cases of anaphylaxis, which is not indicated solely by difficulty breathing and rash. While assessing the client's oxygen saturation is important, discontinuing the potential allergen takes precedence. Contacting the healthcare provider should be done after discontinuing the antibiotic and assessing the client to report the situation and seek further guidance.

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