Nursing Elites

1. After attempting suicide by taking 200 acetaminophen (Tylenol) tablets, a client is transferred from the emergency department to the locked psychiatric unit. The client is now awake and alert but refuses to speak with the nurse. In this situation, what is the nurse’s first priority?

• A. Establish a rapport to foster trust
• B. Place the client in full restraints
• C. Try to communicate with the client in writing
• D. Ensure safety by initiating suicide precautions

Correct answer: D

Rationale: The nurse's first priority in this situation is to ensure the client's safety by initiating suicide precautions. This involves removing any potential means of self-harm and closely monitoring the client to prevent further attempts. While establishing rapport and communication are important, safety is paramount at this critical juncture. Placing the client in full restraints should be avoided unless absolutely necessary for immediate safety concerns.

2. The unlicensed nursing assistant is applying elastic compression stockings to the client. Which action by the assistant warrants immediate intervention by the nurse?

• A. The assistant is putting the stockings on while the client is in the chair
• B. The assistant inserted two (2) fingers under the proximal end of the stocking
• C. The assistant elevated the feet while lying down to put on the stockings
• D. The assistant made sure the toes were warm after putting the stockings on

Correct answer: A

Rationale: The correct answer is A. Compression stockings should be applied while the client is lying down to prevent pooling of blood in the legs, which can occur when the client is sitting or standing. Choice B is incorrect as inserting two fingers under the proximal end of the stocking helps ensure proper fit. Choice C is incorrect as elevating the feet while lying down is a correct technique for applying compression stockings. Choice D is incorrect as ensuring the toes are warm after putting the stockings on is a good practice for client comfort.

3. In a routine sputum analysis, which of the following indicates proper nursing action before sputum collection?

• A. Secure a clean container
• B. Discard the container if the outside becomes dirty
• C. Rinse the client's mouth with Listerine before collection
• D. Tell the client that 4 tablespoons of sputum are needed

Correct answer: A

Rationale: The correct answer is to secure a clean container before sputum collection. This is essential to prevent contamination of the specimen, ensuring accurate test results and avoiding the introduction of external particles or bacteria. Choice B is incorrect because discarding the container if the outside becomes dirty is not necessary; the cleanliness of the inside is crucial. Choice C is incorrect as rinsing the client's mouth with Listerine before collection may introduce unwanted substances that can affect the test results. Choice D is incorrect as the amount of sputum required can vary depending on the test, and specifying a specific amount without medical guidance is not appropriate.

4. The nurse administers 2 units of salt-poor albumin to a client with portal hypertension and ascites. The nurse explains to the client that this is administered to:

• A. Provide nutrients
• B. Increase protein stores
• C. Elevate the circulating blood volume
• D. Divert blood flow away from the liver temporarily

Correct answer: C

Rationale: The correct answer is C: Elevate the circulating blood volume. Salt-poor albumin is given to increase the circulating blood volume, which helps reduce ascites by improving fluid distribution within the body. Choices A, B, and D are incorrect because salt-poor albumin is not administered to provide nutrients, increase protein stores, or divert blood flow away from the liver.

5. Which drugs contribute to peptic ulcers?

• A. Antacids
• B. Certain antibiotics
• C. Cholesterol-lowering medications
• D. Nonsteroidal anti-inflammatory drugs

Correct answer: D

Rationale: Nonsteroidal anti-inflammatory drugs (NSAIDs) are known to contribute to the development of peptic ulcers by affecting the protective lining of the stomach and increasing stomach acid production. This can lead to irritation and ulcer formation. Antacids are actually used to relieve symptoms of peptic ulcers by neutralizing stomach acid. Certain antibiotics may be prescribed to treat H. pylori infection, a common cause of peptic ulcers. Cholesterol-lowering medications are not typically associated with causing peptic ulcers.

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