Nursing Elites

1. A male client, admitted to the mental health unit for a somatoform disorder, becomes angry because he cannot have his pain medication. He demands that the nurse call the healthcare provider and threatens to leave the hospital. What action should the nurse take?

• A. Place the client in seclusion per unit guidelines
• B. Administer a PRN prescription for lorazepam (Ativan)
• C. Call security to help ensure staff and client safety
• D. Ask what other methods he uses to deal with pain

Correct answer: C

Rationale: In this scenario, the nurse should prioritize ensuring safety. When a client becomes aggressive and threatens to leave, calling security is crucial to help maintain a safe environment for both staff and the client. Placing the client in seclusion (choice A) is not the appropriate initial action as it may escalate the situation further. Administering lorazepam (choice B) should not be the first response to behavioral issues. Asking about other pain management methods (choice D) is not the immediate priority when safety is at risk.

2. A client with complaints of shortness of breath and abdominal pain 1 week after bariatric surgery is admitted for follow-up evaluation. Which assessment finding warrants immediate intervention by the nurse?

• A. Rectal temperature of 101°F
• B. Complaints of left shoulder pain
• C. Blood pressure of 88/50 mmHg
• D. Sustained sinus tachycardia

Correct answer: C

Rationale: A blood pressure of 88/50 mmHg indicates possible hypovolemia or shock, which requires immediate attention. Hypotension can be a sign of decreased perfusion to vital organs, potentially leading to organ failure. The other options, such as a rectal temperature of 101°F, complaints of left shoulder pain, or sustained sinus tachycardia, while important, do not present the same level of immediate threat to the client's well-being as a critically low blood pressure.

3. While flushing the proximal port of a triple lumen central venous catheter with heparin solution, the nurse meets resistance. What action should the nurse take?

• A. Remove the cap and apply direct gentle pressure with the syringe
• B. Contact the healthcare provider regarding the need for a chest x-ray
• C. Cover the cap with tape and label the port as being obstructed
• D. Remove the catheter while applying gentle pressure at the insertion site

Correct answer: B

Rationale: When encountering resistance while flushing a central venous catheter, it is crucial to contact the healthcare provider regarding the need for a chest x-ray. This resistance may indicate a blockage within the catheter, a kink, or other issues that could compromise the integrity of the catheter or pose a risk to the patient. It is essential to assess the situation through imaging to determine the appropriate course of action. Option A is incorrect because applying direct pressure could cause damage to the catheter or dislodge any potential blockage. Option C is incorrect as labeling the port as obstructed without further assessment may delay necessary interventions. Option D is incorrect as removing the catheter without proper evaluation can lead to complications and should only be done under the guidance of a healthcare provider.

4. A 20-year-old male client is diagnosed with Ewing’s sarcoma following an examination for a knee injury. Which instruction is most important for the nurse to provide the client?

• A. Take analgesics regularly to manage pain
• B. Notify the healthcare provider if the swelling worsens
• C. Avoid weight-bearing on the affected knee until the injury heals
• D. Seek treatment for the sarcoma immediately

Correct answer: D

Rationale: The most crucial instruction for the nurse to provide the client is to seek treatment for the sarcoma immediately. Ewing's sarcoma is a type of cancer that necessitates prompt and aggressive treatment for the best possible outcome. While managing pain (Choice A) and monitoring swelling (Choice B) are important, addressing the underlying sarcoma is the priority. Instructing the client to avoid weight-bearing (Choice C) is not directly related to the treatment of Ewing's sarcoma and may not be the most critical instruction at this point.

5. When gathering subjective data from a client, what intervention should the nurse implement first?

• A. Listen attentively
• B. Establish rapport
• C. List problems
• D. Clarify inferences

Correct answer: B

Rationale: Establishing rapport is the initial step the nurse should take when gathering subjective data from a client. Building trust and a good relationship with the client creates an environment where the client feels comfortable sharing accurate and honest information. Listening attentively is important but should come after rapport is established to enhance active listening. Listing problems and clarifying inferences are actions that occur later in the assessment process, after the nurse has established a good rapport and obtained a comprehensive understanding of the client's perspective. Therefore, option B is the correct answer.

Similar Questions