Nursing Elites

1. A nurse in a long-term care facility is serving on the ethics committee, which is addressing a client care dilemma. Which of the following strategies will facilitate resolving the dilemma?

• A. Ensure client autonomy only
• B. Consider only medical benefits
• C. Ensure clear communication among the health care team
• D. Identify possible solutions

Correct answer: D

Rationale: In resolving ethical dilemmas, it is essential to identify possible solutions to address the client care dilemma effectively. Option A, 'Ensure client autonomy only,' is not comprehensive enough to resolve complex ethical issues. Option B, 'Consider only medical benefits,' overlooks other important factors beyond medical benefits that are involved in ethical decision-making. Option C, 'Ensure clear communication among the health care team,' is important but may not be sufficient on its own to resolve the ethical dilemma. Therefore, the most effective strategy among the given options is to identify possible solutions to navigate through the ethical dilemma.

2. When caring for a client diagnosed with delirium, which condition is most important for the nurse to investigate?

• A. Cancer of any kind
• B. Impaired hearing
• C. Prescription drug intoxication
• D. Heart failure

Correct answer: C

Rationale: When caring for a client diagnosed with delirium, the most important condition for the nurse to investigate is prescription drug intoxication. Delirium can be caused by various factors, and prescription drug intoxication is a common reversible cause. Investigating this factor first is crucial to identify and address the underlying cause promptly. Choices A, B, and D are less likely to be directly associated with delirium compared to prescription drug intoxication. While cancer, impaired hearing, and heart failure can have their complications and effects, they are not typically the primary causes of delirium in a client.

3. A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following actions should the nurse take?

• A. Administer the TPN through a peripheral IV catheter.
• B. Check the client's capillary blood glucose level every 4 hours.
• C. Heat the TPN solution to room temperature before administering.
• D. Weigh the client every 3 days.

Correct answer: B

Rationale: The correct answer is to check the client's capillary blood glucose level every 4 hours. Clients receiving TPN are at risk for hyperglycemia, so regular monitoring of blood glucose levels is essential to detect and manage hyperglycemia promptly. Administering TPN through a peripheral IV catheter (Choice A) is incorrect as TPN should be given through a central venous catheter to prevent complications. Heating the TPN solution to room temperature (Choice C) is unnecessary and not a standard practice. Weighing the client every 3 days (Choice D) is important for monitoring fluid status but is not the priority action when caring for a client receiving TPN.

4. A healthcare professional is reviewing the medical record of a client who underwent surgery for a hip fracture. Which of the following findings should the healthcare professional report to the provider?

• A. Clear lung sounds
• B. Fever
• C. Pain in the operative leg
• D. Capillary refill of 2 seconds

Correct answer: B

Rationale: The correct answer is B: Fever. Fever in a postoperative client can indicate an infection, which is a serious complication and should be reported immediately to the provider for further evaluation and management. Clear lung sounds (Choice A) are a positive finding indicating normal respiratory function. Pain in the operative leg (Choice C) is expected postoperatively and should be managed with appropriate pain relief measures. Capillary refill of 2 seconds (Choice D) is within the normal range (less than 3 seconds) and is not a concerning finding postoperatively.

5. How should a healthcare professional assess a patient with hyperkalemia?

• A. Monitor ECG and administer insulin
• B. Monitor blood glucose levels and provide fluids
• C. Monitor for muscle weakness and administer calcium gluconate
• D. Monitor electrolyte levels and provide potassium supplements

Correct answer: A

Rationale: Corrected Question: When assessing a patient with hyperkalemia, monitoring the ECG and administering insulin are crucial steps. Hyperkalemia can affect the heart's function, leading to life-threatening arrhythmias. Monitoring the ECG helps in identifying any cardiac abnormalities associated with high potassium levels. Administering insulin, along with glucose, helps shift potassium from the bloodstream into the cells, temporarily lowering the potassium levels. Choice B is incorrect because monitoring blood glucose levels and providing fluids are not the primary interventions for hyperkalemia. Choice C is incorrect as monitoring for muscle weakness and administering calcium gluconate are not the first-line treatments for hyperkalemia. Calcium gluconate may be used in specific situations to stabilize cardiac cell membranes in severe cases of hyperkalemia. Choice D is incorrect because monitoring electrolyte levels and providing potassium supplements would worsen hyperkalemia, as the patient already has elevated potassium levels and does not require additional potassium supplementation.

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