Nursing Elites

1. A nurse in the emergency department is preparing to care for a client who arrived via ambulance. The client is disoriented and has a cardiac arrhythmia. Which of the following actions should the nurse take?

• A. Proceed with treatment without obtaining written consent
• B. Contact the client's next of kin to obtain consent for treatment
• C. Have the client sign a consent for treatment
• D. Notify risk management before initiating treatment

Correct answer: A

Rationale: In emergency situations where a client is disoriented and has a cardiac arrhythmia, obtaining written consent may not be possible due to the urgency of the situation. The priority is to provide immediate treatment to ensure patient safety. Contacting the next of kin or having the client sign a consent form would cause unnecessary delays in providing critical care. Notifying risk management before initiating treatment is not the most appropriate action when dealing with a time-sensitive situation like a cardiac arrhythmia.

2. A nurse is caring for a client who has cancer. The client’s adult child asks the nurse for information about the client’s treatment plan. Which of the following responses should the nurse make?

• A. I will ask your mother's primary care provider to speak with you
• B. What would you like to know about your mother's treatment?
• C. I cannot provide this information to you without your mother's consent
• D. You will have to speak directly to your mother about her treatment

Correct answer: C

Rationale: The nurse should not provide treatment information without the client's consent.

3. Which skin disorder most closely resembles and mimics dandruff?

• A. Lice infestation
• B. Scabies
• C. Dermatitis
• D. Acne vulgaris

Correct answer: C

Rationale: Dermatitis can closely resemble and mimic dandruff due to similar symptoms like flaking and itching. Lice infestation (choice A) is characterized by the presence of lice and their eggs attached to the hair shaft, different from dandruff. Scabies (choice B) is a contagious skin condition caused by mites, presenting as burrows, rashes, and intense itching, not typically resembling dandruff. Acne vulgaris (choice D) is a skin condition involving hair follicles and sebaceous glands, manifesting as pimples and inflammation, which is distinct from dandruff.

4. Who should document care?

• A. The LPNs should document the care that they provided and the care that was given by unlicensed assistive staff.
• B. The registered nurse must document all of the care that is provided by the nursing assistants because they are accountable for all care.
• C. All staff members should document all of the care that they have provided.
• D. All staff should document all of the care that they have provided but the registered nurse, as the only independent practitioner, signs it.

Correct answer: C

Rationale: All staff members should document the care they provided as part of their accountability and to ensure accurate and comprehensive records. In healthcare settings, it is essential for all staff to document the care they deliver for continuity of care and legal purposes. The registered nurse may sign off on the documentation for oversight purposes, but the responsibility of documenting care extends to all staff involved in patient care. Choices A and B incorrectly limit the responsibility to specific roles, while choice D inaccurately suggests that only the registered nurse signs off on the documentation, overlooking the importance of comprehensive documentation by all staff members involved.

5. A nurse caring for a group of clients reviews the electrolyte laboratory results and notes a sodium level of 130 mEq/L on one client's laboratory report. The nurse understands that which client is at highest risk for the development of a sodium value at this level?

• A. The client with renal failure
• B. The client who is taking diuretics
• C. The client with hyperaldosteronism
• D. The client who is taking corticosteroids

Correct answer: B

Rationale: The correct answer is B. Clients taking diuretics are at risk for hyponatremia due to excessive sodium loss. In this scenario, a sodium level of 130 mEq/L indicates hyponatremia, which is commonly associated with diuretic use. Options A, C, and D are not the highest risk factors for developing low sodium levels in this context. Renal failure, hyperaldosteronism, and corticosteroid use are not directly linked to sodium loss as seen with diuretics.

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