Nursing Elites

1. 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.

2. Which of the following actions should the nurse take to ensure the safety of a client using home oxygen?

• A. Allow smoking in designated areas
• B. Keep oxygen tanks upright at all times
• C. Store the oxygen equipment in a closet
• D. Keep oxygen tanks at least 10 feet away from heat sources

Correct answer: B

Rationale: The correct answer is B: 'Keep oxygen tanks upright at all times.' Oxygen tanks should be stored in an upright position to prevent leaks and accidents. Choice A is incorrect as smoking should never be allowed near oxygen due to the risk of fire. Choice C is incorrect as oxygen equipment should be stored in a well-ventilated area, not in a closet. Choice D is incorrect as oxygen tanks must be kept a minimum of 5 to 10 feet away from heat sources to prevent combustion. Therefore, the best practice is to keep oxygen tanks upright to ensure safety.

3. A client with dementia is at risk of falling. What is the best intervention to prevent injury?

• A. Place the client in a room close to the nurses' station
• B. Use a bed exit alarm
• C. Encourage family members to stay with the client at all times
• D. Raise all four side rails

Correct answer: B

Rationale: Using a bed exit alarm is the best intervention to prevent injury in a client with dementia at risk of falling. This device alerts staff when the client attempts to leave the bed, allowing for timely assistance and reducing the risk of falls. Placing the client in a room close to the nurses' station may help with supervision but does not provide immediate alerts like a bed exit alarm. Encouraging family members to stay with the client at all times may not be feasible, and raising all four side rails can lead to restraint issues and is not recommended unless necessary for the client's safety.

4. Which of the following is an early indicator that a client with a tracheostomy may require suctioning?

• A. Decreased respiratory rate
• B. Irritability
• C. Bradycardia
• D. Decreased oxygen saturation

Correct answer: B

Rationale: Irritability is an early indicator that suctioning is necessary for a client with a tracheostomy. Irritability can signal discomfort or difficulty breathing, which may be due to the need for suctioning to clear the airway. Decreased respiratory rate, bradycardia, and decreased oxygen saturation are not typically early indicators that suctioning is needed in a client with a tracheostomy. These symptoms may occur later if the airway is not cleared promptly.

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.

Similar Questions