Nursing Elites

1. A nurse is caring for a client who has an altered mental status and has become aggressive. Which of the following prescriptions should the nurse clarify with the provider prior to administration?

• A. Haloperidol
• B. Zolpidem
• C. Morphine
• D. Lorazepam

Correct answer: B

Rationale: The correct answer is B: Zolpidem. Zolpidem is a sedative-hypnotic medication that can worsen altered mental status, especially in clients who are already aggressive. Therefore, the nurse should clarify this prescription with the provider before administration to ensure it is safe for the client. Choice A, Haloperidol, is an antipsychotic commonly used to manage aggression in clients with altered mental status, making it an appropriate choice in this scenario. Choice C, Morphine, is an opioid analgesic and would not directly impact the client's altered mental status or aggression. Choice D, Lorazepam, is a benzodiazepine used to manage anxiety and agitation, which could be beneficial in this situation but does not have the same potential to exacerbate altered mental status as Zolpidem.

2. A nurse is contributing to the plan of care for a client following a transurethral resection of the prostate (TURP). Which of the following interventions should the nurse include?

• A. Administer antibiotics
• B. Irrigate the bladder using sterile technique
• C. Avoid irrigating the bladder
• D. Insert a urinary catheter

Correct answer: B

Rationale: Irrigating the bladder using sterile technique is crucial in the care of a client following a transurethral resection of the prostate (TURP). This intervention helps prevent infection and maintains patency of the urinary catheter, promoting healing. Administering antibiotics (Choice A) may be necessary if there is an infection present, but it is not a routine intervention following TURP. Avoiding bladder irrigation (Choice C) is not recommended as it can lead to clot retention and other complications. Inserting a urinary catheter (Choice D) is usually already done during the TURP procedure and is not a postoperative intervention.

3. How should a healthcare professional monitor a patient receiving IV potassium?

• A. Monitor ECG for dysrhythmias
• B. Monitor urine output
• C. Monitor serum potassium levels
• D. All of the above

Correct answer: D

Rationale: When a patient is receiving IV potassium, it is crucial to monitor various parameters to ensure patient safety. Monitoring the ECG helps in identifying any potential dysrhythmias that may occur due to potassium imbalances. Monitoring urine output is important as potassium levels can affect renal function. Monitoring serum potassium levels is essential to assess the effectiveness of the IV potassium therapy. Therefore, all the options - monitoring ECG for dysrhythmias, urine output, and serum potassium levels - are necessary when administering IV potassium, making 'All of the above' the correct answer. Choices A, B, and C are not individually sufficient as they each address different aspects of patient monitoring when receiving IV potassium.

4. A nurse is caring for a client who is 1 hr postoperative following rhinoplasty. Which of the following manifestations requires immediate action by the nurse?

• A. Increase in frequency of swallowing.
• B. Moderate sanguineous drainage on the drip pad.
• C. Bruising to the face.
• D. Absent gag reflex.

Correct answer: A

Rationale: The correct answer is A: Increase in frequency of swallowing. After rhinoplasty, an increase in frequency of swallowing may indicate possible bleeding, which requires immediate action by the nurse. The client could be experiencing postoperative bleeding, and prompt intervention is necessary to prevent complications. Choice B, moderate sanguineous drainage on the drip pad, is expected in the immediate postoperative period and does not require immediate action unless it becomes excessive. Choice C, bruising to the face, is a common postoperative finding and does not require immediate action unless it is excessive or affects the airway. Choice D, absent gag reflex, would not be expected immediately following rhinoplasty and would require intervention, but the manifestation of increased swallowing frequency is a higher priority due to its association with potential bleeding.

5. A nurse is caring for a client who has bipolar disorder and is experiencing acute mania. The nurse obtained a verbal prescription for restraints. Which of the following actions should the nurse take?

• A. Request a renewal of the prescription every 8 hours.
• B. Check the client's peripheral pulse rate every 30 minutes.
• C. Obtain a prescription for restraint within 4 hours.
• D. Document the client's condition every 15 minutes.

Correct answer: D

Rationale: In a situation where a verbal prescription for restraints is obtained for a client experiencing acute mania, the nurse should document the client's condition every 15 minutes. This frequent documentation allows for accurate monitoring of the client's condition, ensuring safety and compliance. Requesting a renewal of the prescription every 8 hours (Choice A) is not necessary as the focus should be on monitoring the client's condition. Checking the client's peripheral pulse rate every 30 minutes (Choice B) is not directly related to the need for restraints in this scenario. Obtaining a prescription for restraint within 4 hours (Choice C) is not a priority when a verbal prescription is already obtained and immediate action is needed for the client's safety.

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