Nursing Elites

1. A client who is a Jehovah's Witness is admitted to the nursing unit. Which concern should the nurse have for planning care in terms of the client's beliefs?

• A. Autopsy of the body is prohibited.
• B. Blood transfusions are forbidden.
• C. Alcohol use in any form is not allowed.
• D. A vegetarian diet must be followed.

Correct answer: B

Rationale: The correct answer is B. In the Jehovah's Witness religion, blood transfusions are forbidden due to their beliefs. Autopsy prohibition is in Judaism, while alcohol and drug use is not allowed in Buddhism. While some sects are vegetarian, the critical concern in nursing care for Jehovah's Witnesses is respecting their prohibition of blood transfusions.

2. The health care provider has changed a client's prescription from the PO to the IV route of administration. The nurse should anticipate which change in the pharmacokinetic properties of the medication?

• A. The client will experience increased tolerance to the drug's effects and may need a higher dose.
• B. The onset of action of the drug will occur more rapidly, resulting in a more rapid effect.
• C. The medication will be more highly protein-bound, increasing the duration of action.
• D. The therapeutic index will be increased, placing the client at greater risk for toxicity.

Correct answer: B

Rationale: When a medication is administered via the IV route, the absorptive process is bypassed, leading to a more rapid onset of action. This results in a faster effect of the drug. Choice A is incorrect because changing the route of administration does not necessarily lead to increased tolerance or the need for a higher dose. Choice C is incorrect as changing the route of administration does not directly affect the protein binding of a medication. Choice D is incorrect because increasing the therapeutic index would actually reduce the risk of toxicity, not increase it.

3. The nurse is attempting to pass an indwelling catheter in an adult male and is having difficulty. What is the most appropriate action for the nurse?

• A. Remove the catheter and reinsert it with the client positioned differently.
• B. Try a straight catheter instead.
• C. Try a smaller catheter.
• D. Discontinue the procedure and notify the physician.

Correct answer: D

Rationale: If resistance is encountered, the nurse should discontinue the procedure and notify the physician, as this may indicate an obstruction.

4. The healthcare professional counts an adult's apical heartbeat at 110 beats per minute. The healthcare professional describes this as:

• A. Asystole
• B. Bigeminy
• C. Tachycardia
• D. Bradycardia

Correct answer: C

Rationale: Tachycardia is a heart rate greater than 100 beats per minute. In this case, an adult's heart rate of 110 beats per minute falls within the range of tachycardia. Tachycardia can be a common physiological response to various stresses on the body, leading to an increased heart rate. Asystole refers to the absence of cardiac activity, bigeminy is a specific heart rhythm pattern, and bradycardia is a heart rate below 60 beats per minute in adults.

5. A client in the early stages of Alzheimer’s disease is very anxious and frequently asks about her deceased parents. Which intervention should the nurse implement to reduce the client’s anxiety?

• A. Remind the client that her parents have passed away
• B. Ask the client about her favorite memories with her parents
• C. Engage the client in an activity to distract her from thinking about her parents
• D. Reorient the client to the present reality and surroundings

Correct answer: C

Rationale: Engaging the client in an activity to distract her from thinking about her deceased parents is the most appropriate intervention to reduce anxiety. This approach helps shift the focus away from distressing thoughts and can provide comfort and a sense of calm to the client.

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