Nursing Elites

1. A male client attends a community support program for mentally impaired and chemically abusing clients. The client tells the PN that his drugs of choice are cocaine and heroin. What is the greatest health risk for this client?

• A. Hypertension
• B. Hepatitis
• C. Glaucoma
• D. Diabetes

Correct answer: B

Rationale: The correct answer is B: Hepatitis. Hepatitis is the greatest health risk for this client due to the potential for contracting the disease through needle-sharing, common among drug users. This can lead to serious liver complications. While hypertension, glaucoma, and diabetes are all important health concerns, they are not directly associated with the drug abuse mentioned in the scenario.

2. The nurse is assigned to administer medications in a long-term care facility. A disoriented resident has no identification band or picture. What is the best nursing action for the nurse to take prior to administering the medications to this resident?

• A. Ask a regular staff member to confirm the resident's identity
• B. Hold the medication until a family member can confirm identity
• C. Re-orient the resident to name, place, and situation
• D. Confirm the room and bed numbers with those on the medication record

Correct answer: A

Rationale: In a long-term care facility, when a disoriented resident lacks identification, it is crucial to confirm the resident's identity before administering medication to prevent errors. Asking a regular staff member who is familiar with the resident to confirm their identity is the best course of action. This ensures accuracy and safety in medication administration. Holding the medication until a family member can confirm the identity could delay necessary treatment. Re-orienting the resident is important for their well-being but does not address the immediate medication safety concern. Confirming room and bed numbers, though important for administration logistics, does not verify the resident's identity.

3. A client with blood type AB negative delivers a newborn with blood type A positive. The cord blood reveals a positive indirect Coombs test. Which is the implication of this finding?

• A. The newborn is infected with an infectious blood-borne disease
• B. The newborn needs phototherapy for physiologic jaundice
• C. The mother's Rh antibodies are present in the neonatal blood
• D. The mother no longer needs Rho immune globulin injections

Correct answer: C

Rationale: A positive indirect Coombs test indicates that the mother's Rh antibodies have crossed the placenta and are present in the neonatal blood, which can lead to hemolytic disease of the newborn. This finding necessitates close monitoring and potential intervention. Choice A is incorrect because a positive Coombs test does not indicate an infectious blood-borne disease. Choice B is incorrect as phototherapy for physiologic jaundice is not related to a positive Coombs test result. Choice D is incorrect because a positive Coombs test does not indicate that the mother no longer needs Rho immune globulin injections; in fact, it suggests a need for further management to prevent hemolytic disease of the newborn.

4. An 8-year-old is placed in 90-90 traction for a fractured femur resulting from a motor vehicle collision. Which finding requires further action by the nurse?

• A. No bowel movement for two days
• B. Mother assists child in changing positions
• C. Weights are touching the foot of the bed
• D. Child is able to move the toes freely when tickled

Correct answer: C

Rationale: The correct answer is C. In 90-90 traction, the weights should hang freely and not touch the foot of the bed to maintain proper traction and bone alignment. Option A is not necessarily a concern as bowel movements can be influenced by various factors, including diet changes and pain medication. Option B indicates good caregiver involvement, promoting comfort and preventing complications. Option D demonstrates neurovascular function, which is a positive finding. Therefore, the weights touching the foot of the bed is the finding that requires immediate attention to ensure the effectiveness of the traction.

5. The UAP reports to the PN that an assigned client experiences SOB when the bed is lowered for bathing. Which action should the PN implement?

• A. Obtain further data about the client's activity intolerance to position changes
• B. Advise the UAP to allow the client to rest before completing the bath
• C. Direct the UAP to obtain vital signs and a pulse oximetry reading
• D. Notify the healthcare provider about the client's episode of SOB

Correct answer: B

Rationale: Advising the UAP to allow the client to rest before completing the bath is the most appropriate action to take. This helps manage the shortness of breath (SOB) experienced by the client and prevents further stress. By giving the client time to rest, the PN ensures the client's comfort and safety during care activities. The other options are not the most immediate or appropriate actions in this scenario: obtaining further data about activity intolerance (choice A) may delay addressing the current issue, obtaining vital signs and pulse oximetry (choice C) is important but not as immediate as allowing the client to rest, and notifying the healthcare provider (choice D) is premature before trying a simple intervention like allowing the client to rest.

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