Nursing Elites

1. A nurse has just received change-of-shift report for four clients. Which of the following clients should the nurse assess first?

• A. A client who was just given a glass of orange juice for a low blood glucose level.
• B. A client who is scheduled for a procedure in 1 hr.
• C. A client who has 100 mL fluid remaining in his IV bag.
• D. A client who received a pain medication 30 min ago for postoperative pain.

Correct answer: A

Rationale: The client with low blood glucose needs immediate assessment to ensure that the orange juice has corrected the hypoglycemia. Monitoring the effectiveness of the intervention for low blood glucose is the priority. The other options, such as a client scheduled for a procedure in 1 hour, a client with fluid remaining in the IV bag, and a client who received pain medication 30 minutes ago, do not require immediate assessment like the client with low blood glucose.

2. What should a healthcare provider prioritize for a client diagnosed with bipolar disorder?

• A. Monitor for hyperactivity
• B. Monitor for signs of depression
• C. Monitor for changes in self-esteem
• D. Monitor for changes in energy levels

Correct answer: B

Rationale: When caring for a client diagnosed with bipolar disorder, the priority is to monitor for signs of depression. Individuals with bipolar disorder are at risk of severe depressive episodes, making it crucial to watch for signs of depression. While changes in energy levels and self-esteem are common in bipolar disorder, they are not the primary focus. Hyperactivity is a characteristic of the manic phase of bipolar disorder, so monitoring for depression is the priority in this case.

3. A nurse is providing discharge instructions to a client who has a prescription for the use of oxygen in his home. Which of the following should the nurse teach the client about using oxygen safely in his home?

• A. Family members who smoke should be at least 10 ft away from the client when oxygen is in use
• B. Nail polish should not be used near a client who is receiving oxygen
• C. A 'No Smoking' sign should be placed on the front door
• D. Cotton bedding and clothing should be replaced with items made from wool

Correct answer: C

Rationale: The correct answer is C. Placing a 'No Smoking' sign on the front door is crucial for fire safety when using oxygen at home. Choice A is incorrect as family members who smoke should not be around the client when oxygen is in use, not just at a distance. Choice B is not directly related to oxygen safety. Choice D is also irrelevant as the type of bedding and clothing material does not impact oxygen safety.

4. How should a healthcare provider respond to a patient experiencing acute chest pain?

• A. Administer prescribed nitroglycerin
• B. Provide oxygen
• C. Call for emergency assistance
• D. Reassure the patient

Correct answer: A

Rationale: In the case of a patient experiencing acute chest pain, the initial response should include administering prescribed nitroglycerin. Nitroglycerin helps dilate blood vessels and improve blood flow to the heart, which can be beneficial in managing chest pain related to cardiac issues. Providing oxygen can also be helpful to support oxygenation. However, the priority in this scenario is to address the potential cardiac cause by administering nitroglycerin. Calling for emergency assistance is crucial if the patient's condition does not improve or deteriorates. Reassuring the patient is essential for emotional support but should not be the primary intervention in the case of acute chest pain.

5. A client who decides not to have surgery despite significant blockages in his coronary arteries is an example of what principle?

• A. Fidelity
• B. Autonomy
• C. Justice
• D. Non-maleficence

Correct answer: B

Rationale: The correct answer is B: Autonomy. Autonomy in healthcare refers to respecting a patient's right to make decisions about their own care, even if those decisions may not align with healthcare providers' recommendations. In this scenario, the client's decision not to have surgery despite significant blockages in his coronary arteries demonstrates his autonomy in making choices about his own health. Choice A, Fidelity, refers to the concept of keeping promises and being faithful to commitments, which is not applicable in this situation. Choice C, Justice, involves fairness and equal treatment in healthcare, which is not the primary principle at play when a patient exercises autonomy. Choice D, Non-maleficence, relates to the principle of doing no harm, which is important but not directly relevant to the client's decision to refuse surgery.

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