Nursing Elites

1. A client is scheduled for a spiral CT scan with contrast to evaluate for pulmonary embolism. Which information in the client's history requires follow-up by the nurse?

• A. Is allergic to shellfish
• B. Has a history of smoking
• C. Takes metformin for type 2 diabetes mellitus
• D. Has hypertension controlled with medication

Correct answer: A

Rationale: An allergy to shellfish often indicates an allergy to iodine, which is used in contrast dyes for CT scans. This poses a significant risk of an allergic reaction during the procedure. The nurse must ensure appropriate precautions or alternative imaging are considered. Choices B, C, and D are not directly contraindicated for a CT scan with contrast. Smoking history, metformin use, and controlled hypertension do not typically impact the safety or feasibility of the procedure.

2. A client with a tracheostomy develops copious, thick secretions. What is the nurse's priority action?

• A. Increase the client's fluid intake.
• B. Perform tracheal suctioning.
• C. Administer a mucolytic agent.
• D. Increase the humidity of the oxygen source.

Correct answer: D

Rationale: The correct answer is to increase the humidity of the oxygen source. This action helps thin thick secretions, making them easier to clear from the tracheostomy tube. Increasing fluid intake (Choice A) can be beneficial in some cases but addressing humidity is more specific to managing thick secretions in a client with a tracheostomy. Tracheal suctioning (Choice B) should be done after attempting to thin the secretions with increased humidity. Administering a mucolytic agent (Choice C) is a possible intervention but typically comes after addressing humidity and before resorting to suctioning to avoid unnecessary invasiveness.

3. The nurse is caring for a client in atrial fibrillation. The atrial heart rate is 250, and the ventricular rate is controlled at 75. Which of the following findings is cause for the most concern?

• A. Diminished bowel sounds
• B. Loss of appetite
• C. A cold, pale lower leg
• D. Tachypnea

Correct answer: C

Rationale: A cold, pale lower leg is cause for the most concern as it could indicate compromised blood circulation, potentially leading to serious complications like ischemia or thrombosis. Diminished bowel sounds, loss of appetite, and tachypnea are not directly related to the client's condition in atrial fibrillation and the heart rate discrepancy.

4. The nurse receives a report on an older adult client with middle stage dementia. What information suggests the nurse should do immediate follow-up rather than delegate care to the nursing assistant?

• A. Has had a change in respiratory rate with an increase of 2 breaths
• B. Has had a change in heart rate with an increase of 10 beats
• C. Was minimally responsive to voice and touch
• D. Has had a blood pressure change with a drop of 8 mmHg systolic

Correct answer: C

Rationale: A change in responsiveness, as indicated by being minimally responsive to voice and touch, suggests a potential acute issue that requires immediate nursing assessment and intervention rather than delegation. Changes in vital signs (choices A, B, D) can be important but do not always indicate an immediate need for nursing intervention compared to a change in responsiveness.

5. A client with a diagnosis of bipolar disorder has been referred to a local boarding home for consideration for placement. The social worker telephoned the hospital unit for information about the client's mental status and adjustment. The appropriate response of the nurse should be which of these statements?

• A. I am sorry. Referral information can only be provided by the client's health care providers.
• B. I can never give any information out by telephone. How do I know who you are?
• C. Since this is a referral, I can give you this information.
• D. I need to get the client's written consent before I release any information to you.

Correct answer: D

Rationale: The correct answer is D: "I need to get the client's written consent before I release any information to you." In this scenario, the nurse must obtain the client's written consent before disclosing any information to the social worker. This process ensures compliance with privacy laws like HIPAA, which are designed to protect client confidentiality. Choice A is incorrect because it does not address the need for consent. Choice B is incorrect as it is unprofessional and does not focus on obtaining consent. Choice C is incorrect as it suggests information can be shared without consent, which goes against privacy laws.

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