Nursing Elites

1. A nurse is caring for a client who is requesting to leave the facility against medical advice (AMA). The client states, 'I am ready to go immediately.' Which of the following actions should the nurse take first?

• A. Teach the client about the potential health risks of leaving early
• B. Ask the client to sign a document stating they are leaving AMA
• C. Document the client's statement in direct quotes in the medical record
• D. Complete an incident report detailing the client scenario

Correct answer: A

Rationale: The correct action for the nurse to take first is to educate the client about the potential health risks of leaving against medical advice (AMA). By providing this information, the nurse can help the client make an informed decision regarding their healthcare. Choice B, asking the client to sign a document, can be done after the client has been informed about the risks. Choice C, documenting the client's statement, is important but should not take precedence over educating the client. Choice D, completing an incident report, is not the priority when a client is requesting to leave AMA.

2. A client reports difficulty sleeping while in the hospital. Which of the following actions taken by the assistive personnel (AP) while the client is sleeping should prompt the nurse to intervene?

• A. Closes the door to the client's room
• B. Flushes the client's toilet after emptying the urinary catheter's drainage bag
• C. Measures the client's vital signs routinely
• D. Asks a group of personnel in the hall to speak quietly

Correct answer: B

Rationale: The correct answer is B because flushing the client's toilet after emptying the urinary catheter's drainage bag could disturb the client's rest. The nurse should intervene to ensure a restful environment for the client. Choices A, C, and D are not actions that would be disruptive to the client's sleep. Closing the door to the client's room, measuring vital signs routinely, and asking personnel in the hall to speak quietly are appropriate actions that do not directly disturb the client's rest.

3. When administering IV fluids to a dehydrated patient, what is the nurse's priority assessment?

• A. Monitor the patient's electrolyte levels.
• B. Assess the patient's blood pressure regularly.
• C. Monitor the patient's heart rate every 4 hours.
• D. Check the patient's urine output hourly.

Correct answer: B

Rationale: The correct answer is to assess the patient's blood pressure regularly. Monitoring blood pressure is crucial when administering IV fluids to a dehydrated patient as it helps in evaluating the patient's fluid status. Changes in blood pressure can indicate the effectiveness of the fluid therapy, the patient's response to treatment, and the possibility of complications such as fluid overload or hypovolemia. Monitoring electrolyte levels (Choice A) is essential but not the priority when assessing a dehydrated patient receiving IV fluids. Heart rate (Choice C) should be monitored more frequently than every 4 hours in such a situation. Checking urine output (Choice D) is important but not as critical as assessing blood pressure in this scenario.

4. A healthcare professional is giving a change-of-shift report about a client admitted earlier that day with pneumonia. Which of the following pieces of information is the priority for the healthcare professional to provide?

• A. Recent chest x-ray results
• B. Medication history
• C. Breath sounds
• D. Lab results

Correct answer: C

Rationale: The correct answer is C: 'Breath sounds.' When providing a change-of-shift report for a client with pneumonia, the priority information to communicate is the assessment of breath sounds. Monitoring breath sounds is crucial in assessing respiratory status and the effectiveness of treatments in pneumonia. Option A, recent chest x-ray results, may be important but does not provide real-time information on the client's current status. Option B, medication history, is relevant but not as immediate as assessing breath sounds. Option D, lab results, can provide valuable information but may not be as urgent as monitoring the client's respiratory status through breath sounds.

5. A nurse is caring for a client who requires total parenteral nutrition (TPN). Which of the following actions should the nurse take when finding that the TPN solution is infusing too rapidly?

• A. Sit the client upright
• B. Stop the TPN infusion
• C. Turn the client on their left side
• D. Prepare to add insulin to the TPN infusion

Correct answer: B

Rationale: The correct action for the nurse to take when finding that the TPN solution is infusing too rapidly is to stop the TPN infusion. This is crucial to prevent fluid overload and ensure the client's safety. Sitting the client upright (Choice A) or turning the client on their left side (Choice C) are not appropriate responses to a rapidly infusing TPN solution and do not address the immediate issue of preventing complications from the rapid infusion. Adding insulin to the TPN infusion (Choice D) is not indicated unless specifically prescribed by the healthcare provider for the client's condition. Therefore, the priority action is to stop the TPN infusion to prevent potential harm.

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