Nursing Elites

1. When assessing a client with a diagnosis of bipolar disorder who reports taking a handful of medications, what information is most important to obtain?

• A. What drugs the client used in the suicide attempt.
• B. When the client last took medications for bipolar disorder.
• C. Whether the client has attempted suicide before.
• D. Which family member has the suicide note.

Correct answer: A

Rationale: The correct answer is to obtain information on what drugs the client used in the suicide attempt. This information is crucial for assessing the severity of the overdose, potential drug interactions, and determining the appropriate treatment plan. Choice B is not as urgent as identifying the drugs taken during the suicide attempt. Choice C, while important, is not as immediately critical as knowing the specific medications involved. Choice D is unrelated to the immediate medical needs of the client.

2. A 5-week-old infant who developed projectile vomiting over the last two weeks is diagnosed with hypertrophic pyloric stenosis. Which intervention should the nurse plan to implement?

• A. Instruct the mother to give the child sugar water only.
• B. Offer oral rehydration solution every 2 hours.
• C. Provide Pedialyte feedings via nasogastric tube.
• D. Maintain intravenous fluid therapy per prescription.

Correct answer: D

Rationale: The correct intervention for a 5-week-old infant diagnosed with hypertrophic pyloric stenosis and experiencing projectile vomiting is to maintain intravenous fluid therapy. Intravenous fluids are crucial for rehydrating an infant suffering from dehydration due to rapid fluid loss from vomiting. Instructing the mother to provide sugar water only (choice A) is inappropriate and insufficient for rehydration. Offering oral rehydration solution every 2 hours (choice B) may not be effective if the infant continues to vomit. Providing Pedialyte feedings via nasogastric tube (choice C) may also not be as effective as intravenous fluid therapy in rapidly replenishing fluids and stabilizing the child's condition.

3. A client with diabetes mellitus presents with a blood sugar level of 320 mg/dL. What is the nurse's initial action?

• A. Administer sliding scale insulin as prescribed
• B. Encourage the client to drink fluids
• C. Provide the client with a carbohydrate snack
• D. Assess the client for signs of hypoglycemia

Correct answer: A

Rationale: When a client with diabetes mellitus presents with a high blood sugar level of 320 mg/dL, the nurse's initial action should be to administer sliding scale insulin as prescribed. The priority is to bring down the elevated glucose level promptly to prevent further complications. Encouraging the client to drink fluids or providing a carbohydrate snack would not effectively address the elevated blood sugar level in this scenario. Assessing for signs of hypoglycemia is not appropriate as the client's blood sugar level is high, not low.

4. Prolonged exposure to high concentrations of supplemental oxygen over several days can cause which pathophysiological effect?

• A. Reduced cardiac output
• B. Disrupted surfactant production
• C. Hyperactivity of alveoli
• D. Increased oxygen carrying capacity

Correct answer: B

Rationale: Corrected Rationale: Prolonged exposure to high oxygen concentrations can disrupt the production of surfactant in the lungs, leading to atelectasis and other lung complications. Surfactant is essential for maintaining lung compliance and preventing alveolar collapse. Reduced cardiac output (Choice A) is not directly associated with prolonged oxygen exposure. Hyperactivity of alveoli (Choice C) is not a recognized consequence of high oxygen levels. Increased oxygen carrying capacity (Choice D) is not a pathophysiological effect of prolonged high oxygen exposure.

5. The nurse is developing an educational program for older clients discharged with new antihypertensive medications. The nurse should ensure that the education materials include which characteristics?

• A. Uses pictures to help illustrate complex ideas
• B. Contains a list with definitions of unfamiliar terms
• C. Uses common words with few syllables
• D. All of the above

Correct answer: D

Rationale: The correct answer is D, 'All of the above.' When developing educational materials for older clients with new antihypertensive medications, it is essential to include characteristics such as using pictures to illustrate complex ideas, providing a list with definitions of unfamiliar terms, and using common words with few syllables. These features help enhance understanding and medication adherence, especially for older adults who may have challenges with health literacy. Choices A, B, and C collectively address the need for simplicity, visual support, and clarification of terms in educational materials, making them crucial for effective patient education.

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