Nursing Elites

1. A client with a history of closed head injury has a radial artery catheter in place and complains of numbness and pain distal to the insertion site. What action should the nurse take?

• A. Monitor the site for further complications.
• B. Promptly remove the catheter from the radial artery.
• C. Elevate the client’s arm above the heart.
• D. Notify the healthcare provider and prepare for surgery.

Correct answer: B

Rationale: A weak pulse and numbness distal to a radial artery catheter may indicate occlusion or damage to the artery, and immediate removal of the catheter is necessary to prevent complications. Therefore, promptly removing the catheter from the radial artery (Choice B) is the correct action. Monitoring the site (Choice A) would delay necessary intervention, elevating the client's arm (Choice C) may not address the underlying issue, and notifying the healthcare provider for surgery (Choice D) without removing the catheter promptly could lead to further complications.

2. A client presents with severe dehydration due to prolonged vomiting. What is the nurse's priority intervention?

• A. Encourage the client to drink clear fluids.
• B. Assess the client's skin turgor and mucous membranes.
• C. Monitor the client's vital signs frequently.
• D. Administer an antiemetic as prescribed.

Correct answer: B

Rationale: The correct answer is to assess the client's skin turgor and mucous membranes. When a client presents with severe dehydration, assessing skin turgor (elasticity of the skin) and mucous membranes (such as checking for dryness in the mouth) is crucial in determining the extent of dehydration. Encouraging the client to drink clear fluids (Choice A) may be important but assessing dehydration severity takes precedence. Monitoring vital signs (Choice C) is essential but assessing dehydration status comes first. Administering an antiemetic (Choice D) addresses vomiting but does not directly assess dehydration.

3. The nurse is providing care for a client with advanced liver disease who is experiencing ascites. Which intervention should the nurse implement to help manage the client's fluid volume?

• A. Increase the client's sodium intake
• B. Encourage the client to drink more fluids
• C. Place the client in a supine position
• D. Administer a diuretic as prescribed

Correct answer: D

Rationale: Administering a diuretic as prescribed is the most appropriate intervention to manage fluid volume in a client with ascites due to advanced liver disease. Diuretics help reduce fluid accumulation in the body, including the abdominal cavity where ascites occurs. Increasing sodium intake would worsen fluid retention, and encouraging more fluid intake can exacerbate ascites. Placing the client in a supine position does not directly address the fluid volume issue associated with ascites.

4. A client with a history of atrial fibrillation is prescribed warfarin. What is the nurse's priority teaching?

• A. Avoid eating foods high in potassium.
• B. Avoid foods high in vitamin K.
• C. Take the medication on an empty stomach.
• D. Take the medication at bedtime for best results.

Correct answer: B

Rationale: The correct answer is B: 'Avoid foods high in vitamin K.' Warfarin is an anticoagulant medication that works by interfering with vitamin K-dependent clotting factors. Therefore, consuming foods high in vitamin K can affect the medication's effectiveness. Choices A, C, and D are incorrect because: A) Warfarin is not affected by foods high in potassium; C) Warfarin should be taken with food to minimize gastrointestinal side effects; D) There is no specific requirement for taking warfarin at bedtime for best results.

5. A client frequently admitted to the locked psychiatric unit repeatedly compliments and invites one of the nurses to go out on a date. The nurse's response should be to

• A. Ask not to be assigned to this client or to work on another unit
• B. Tell the client that such behavior is inappropriate
• C. Inform the client that hospital policy prohibits staff from dating clients
• D. Discuss the boundaries of the therapeutic relationship with the client

Correct answer: D

Rationale: The correct response for the nurse in this situation is to discuss the boundaries of the therapeutic relationship with the client. By doing so, the nurse can reinforce professionalism, establish clear boundaries, and prevent ethical conflicts. Option A is incorrect because avoiding the client or unit does not address the issue at hand and may compromise patient care. Option B, while acknowledging the behavior, does not address the underlying reasons and boundaries. Option C, stating hospital policy, is not as therapeutic or client-centered as discussing the therapeutic relationship directly.

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