Nursing Elites

1. A client with a BMI of 60.2 kg/m² is admitted to the intensive care unit 3 weeks after gastric bypass with gastric rupture and impending multiple organ dysfunction syndrome (MODS). What should the nurse prepare to implement first?

• A. Mechanical ventilation
• B. Platelet transfusion
• C. Loop diuretic therapy
• D. Cyanocobalamin administration

Correct answer: A

Rationale: In this critical situation with gastric rupture and impending MODS, the priority intervention should be mechanical ventilation. This client is at risk of respiratory compromise due to the severity of the condition. Platelet transfusion (Choice B) is not the priority as there is no indication of significant bleeding. Loop diuretic therapy (Choice C) and cyanocobalamin administration (Choice D) are not the immediate priorities in this scenario and would not address the urgent need for respiratory support.

2. When caring for a client with acute respiratory distress syndrome (ARDS), why does the nurse elevate the head of the bed 30 degrees?

• A. To reduce abdominal pressure on the diaphragm
• B. To promote retraction of the intercostal accessory muscles of respiration
• C. To promote bronchodilation and effective airway clearance
• D. To decrease pressure on the medullary center which stimulates breathing

Correct answer: A

Rationale: Elevating the head of the bed to 30 degrees is done to reduce abdominal pressure on the diaphragm, aiding in lung expansion and oxygenation. This position helps improve respiratory mechanics by allowing the diaphragm to move more effectively. Choice B is incorrect as elevating the head of the bed does not directly promote retraction of the intercostal accessory muscles of respiration. Choice C is incorrect because although elevating the head of the bed can assist with airway clearance, its primary purpose in ARDS is to decrease pressure on the diaphragm. Choice D is incorrect because reducing pressure on the medullary center is not the main goal of elevating the head of the bed; the focus is on enhancing lung function and oxygen exchange.

3. When designing a program to provide primary preventative health care to a community-based healthcare system, which service should the nurse consider for inclusion in the program? Select all that apply.

• A. Breast screening for older women
• B. Rehabilitation services for stroke victims
• C. Blood pressure assessments
• D. Antepartum nutritional counseling

Correct answer: A

Rationale: The correct answer is A: Breast screening for older women. In the context of primary preventative health care, breast screening for older women is crucial for early detection of breast cancer. Choice B, rehabilitation services for stroke victims, focuses on rehabilitative care rather than primary preventative care. Choice C, blood pressure assessments, is important for monitoring health status but not exclusive to primary prevention. Choice D, antepartum nutritional counseling, is more related to prenatal care than primary preventative health care. Therefore, choices B, C, and D do not directly align with the primary preventative health care objective of the grant.

4. After witnessing a preoperative client sign the surgical consent form, what are the legal implications of the nurse's signature on the client's form as a witness?

• A. The client voluntarily grants permission for the procedure to be done
• B. The surgeon has explained to the client why the surgery is necessary
• C. The client is competent to sign the consent without impairment of judgment
• D. The client understands the risks and benefits associated with the procedure

Correct answer: C

Rationale: The nurse's signature on the consent form signifies that the client is competent to sign the consent without impairment of judgment. This legal implication ensures that the client possesses the necessary capacity to make decisions about their healthcare. Choice A is incorrect because the nurse's signature does not imply the client's voluntary permission for the procedure. Choice B is incorrect as it pertains to the surgeon's responsibility, not the nurse's. Choice D is incorrect as the nurse's signature does not confirm the client's understanding of the risks and benefits associated with the procedure.

5. A male client with cirrhosis has jaundice and pruritus. He tells the nurse that he has been soaking in hot baths at night with no relief of his discomfort. What action should the nurse take?

• A. Explain that the symptoms are caused by liver damage and can be managed
• B. Obtain a PRN prescription for an analgesic that the client can use for symptom relief
• C. Encourage the client to use cooler water and apply oil-based lotion after soaking
• D. Suggest that the client take brief showers and apply oil-based lotion after showering

Correct answer: D

Rationale: Cooler water and oil-based lotion can help relieve pruritus and improve comfort in clients with cirrhosis experiencing jaundice and pruritus. Hot baths can exacerbate itching, so it is important to suggest cooler showers instead. Choice A is incorrect because symptoms like pruritus can be managed. Choice B is not the most appropriate initial intervention for pruritus related to liver disease. Choice C suggests the use of calamine lotion, which may not be as effective as oil-based lotion for relieving pruritus in this case.

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