Nursing Elites

1. A client with antisocial personality disorder repeatedly requests a specific nurse be assigned to him and is belligerent when another nurse is assigned. What action should the charge nurse implement?

• A. Remind the client that nurse assignments are not based on patient requests
• B. Assign the nurse requested by the client to avoid further conflict
• C. Tell the client that he can request a different nurse if unhappy
• D. Explain the situation calmly and reinforce the rules regarding nurse assignments

Correct answer: A

Rationale: The correct action for the charge nurse to implement is to remind the client that nurse assignments are not based on patient requests. In this situation, it is essential to establish boundaries and communicate that nurse assignments are made based on clinical decisions, not patient preferences. Option B is incorrect because it compromises the principle of fairness in nurse assignments. Option C is incorrect as it encourages the client's behavior by allowing him to request a different nurse based on personal preferences. Option D is also incorrect as it does not address the issue of patient manipulation and reinforces inappropriate behavior.

2. The nurse is caring for a client with a suspected myocardial infarction (MI). Which laboratory test result is most indicative of a recent MI?

• A. Elevated troponin levels
• B. Increased white blood cell count
• C. Increased lactate dehydrogenase (LDH)
• D. Elevated C-reactive protein (CRP)

Correct answer: A

Rationale: Elevated troponin levels are the most specific and sensitive indicator of myocardial infarction. Troponin levels increase within hours of an MI and remain elevated for several days. White blood cell count, lactate dehydrogenase (LDH), and C-reactive protein (CRP) are not specific markers for MI. An increased white blood cell count may indicate inflammation or infection, increased LDH levels can be seen in various conditions like liver disease or muscle injury, and elevated CRP is a general marker of inflammation rather than specific to MI.

3. A client is receiving continuous intravenous heparin for a deep vein thrombosis. Which laboratory result should the nurse monitor to ensure therapeutic heparin levels?

• A. International normalized ratio (INR)
• B. Activated partial thromboplastin time (aPTT)
• C. Hemoglobin
• D. Platelet count

Correct answer: B

Rationale: The activated partial thromboplastin time (aPTT) is the most accurate measure of heparin's therapeutic effect. Heparin increases the time it takes for blood to clot, and the aPTT helps determine whether the dose is within the desired range for anticoagulation therapy. Monitoring the INR, hemoglobin, or platelet count is not specific to assessing therapeutic heparin levels and may not reflect the anticoagulant effect of heparin.

4. A client with advanced chronic kidney disease (CKD) is scheduled for hemodialysis. Which dietary instruction should the nurse provide to the client?

• A. Limit fluid intake to prevent fluid overload
• B. Increase sodium intake to improve fluid balance
• C. Increase potassium intake to prevent hypokalemia
• D. Increase protein intake to promote healing

Correct answer: A

Rationale: The correct answer is A: 'Limit fluid intake to prevent fluid overload.' Clients with advanced chronic kidney disease are at risk of fluid retention, which can lead to complications like fluid overload and hypertension. Therefore, it is crucial to instruct the client to limit fluid intake. Choice B is incorrect because increasing sodium intake can exacerbate fluid retention and hypertension in clients with CKD. Choice C is incorrect as increasing potassium intake can be dangerous for clients with CKD who may already have elevated potassium levels. Choice D is incorrect because while protein intake may need to be adjusted for clients on hemodialysis, the priority in this case is managing fluid intake.

5. Which intervention should the nurse include in the care plan for a child with tetanus?

• A. Ensure proper hydration
• B. Administer prescribed antibiotics
• C. Monitor vital signs frequently
• D. Minimize the amount of stimuli in the room

Correct answer: D

Rationale: The correct intervention for a child with tetanus is to minimize the amount of stimuli in the room. Tetanus causes severe muscle spasms and sensitivity to stimuli, so reducing stimuli like light, sound, and touch can help prevent painful spasms. While ensuring proper hydration and administering antibiotics are essential components of care, minimizing stimuli is crucial for the child's comfort and safety as it directly addresses the symptoms associated with tetanus.

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