Nursing Elites

1. A client with a DNR order has requested resuscitation during a visit from the family. What is the nurse's best course of action?

• A. Follow the family's request and perform CPR.
• B. Explain to the family that the DNR must be honored.
• C. Call the healthcare provider to cancel the DNR order.
• D. Delay resuscitation until further clarification can be made.

Correct answer: B

Rationale: The correct course of action for the nurse is to explain to the family that the DNR (Do Not Resuscitate) order must be honored. It is essential for the nurse to uphold the client's wishes as documented in the DNR order. Performing CPR against the client's expressed wishes in the DNR order would violate ethical and legal standards. Calling the healthcare provider to cancel the DNR order without the client's consent is inappropriate and goes against the client's autonomy. Delaying resuscitation can be detrimental in an emergency situation and may not align with the client's wishes as outlined in the DNR order.

2. A client who has a new prescription for ferrous sulfate is being taught by a nurse. Which of the following statements by the client indicates an understanding of the teaching?

• A. I should expect dark tarry stools.
• B. I should expect increased bruising.
• C. I will not get as many infections.
• D. I will expect the color of my urine to be amber.

Correct answer: A

Rationale: The correct answer is A. When taking ferrous sulfate, dark tarry stools can occur as a common side effect due to the iron content in the medication. This is a normal response to the medication and not a cause for concern. Choices B, C, and D are incorrect because increased bruising, reduced infections, and amber-colored urine are not expected side effects of ferrous sulfate.

3. When administering IV fluids to a dehydrated patient, what is the nurse's priority assessment?

• A. Monitor the patient's electrolyte levels.
• B. Assess the patient's blood pressure regularly.
• C. Monitor the patient's heart rate every 4 hours.
• D. Check the patient's urine output hourly.

Correct answer: B

Rationale: The correct answer is to assess the patient's blood pressure regularly. Monitoring blood pressure is crucial when administering IV fluids to a dehydrated patient as it helps in evaluating the patient's fluid status. Changes in blood pressure can indicate the effectiveness of the fluid therapy, the patient's response to treatment, and the possibility of complications such as fluid overload or hypovolemia. Monitoring electrolyte levels (Choice A) is essential but not the priority when assessing a dehydrated patient receiving IV fluids. Heart rate (Choice C) should be monitored more frequently than every 4 hours in such a situation. Checking urine output (Choice D) is important but not as critical as assessing blood pressure in this scenario.

4. A nurse is preparing to transfer a client who can bear weight on one leg from the bed to a chair. After securing a safe environment, which of the following actions should the nurse take next?

• A. Check for orthostatic hypotension
• B. Use a gait belt
• C. Position the chair on the strong side
• D. Ask for assistance

Correct answer: A

Rationale: The correct next action for the nurse to take is to check for orthostatic hypotension. This step is crucial as it ensures the client's safety during the transfer process. Orthostatic hypotension is a drop in blood pressure that can occur when a person moves from a lying down position to a sitting or standing position. By checking for orthostatic hypotension before transferring the client, the nurse can prevent potential complications such as dizziness, lightheadedness, or falls. Choices B, C, and D are incorrect in this scenario as they do not address the immediate safety concern of assessing for orthostatic hypotension.

5. A patient is admitted with signs of stroke. Which of the following diagnostic tests should the nurse anticipate as the priority?

• A. CT scan
• B. MRI
• C. X-ray
• D. Ultrasound

Correct answer: A

Rationale: A CT scan is the priority diagnostic test to identify and confirm the location and severity of a stroke.

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