Nursing Elites

1. A client is scheduled to have his alanine aminotransferase (ALT) level checked. The client asks the nurse to explain the laboratory test. Which of the following is an appropriate response by the nurse?

• A. “This test will indicate if you are at risk for developing blood clots.”
• B. “This test will determine if your heart is performing properly.”
• C. “This test will provide information about the function of your liver.”
• D. “This test is used to check how your kidneys are working.”

Correct answer: C

Rationale: The correct answer is C: “This test will provide information about the function of your liver.” Alanine aminotransferase (ALT) is an enzyme mainly found in the liver. An elevated ALT level may indicate liver damage or disease. Choices A, B, and D are incorrect because ALT is specifically related to liver function and not indicative of blood clot risk, heart performance, or kidney function.

2. A client is about to undergo emergency abdominal surgery for appendicitis. A healthcare professional is demonstrating postoperative deep breathing and coughing exercises to the client. The healthcare professional realizes the client may be unprepared to learn if the client:

• A. Is not feeling well
• B. Reports severe pain
• C. Has low blood pressure
• D. Is anxious

Correct answer: B

Rationale: Severe pain can be a significant distraction and impediment to the learning process. When a client is experiencing severe pain, their focus and attention are primarily directed towards managing the pain, making it difficult for them to absorb and retain new information effectively. Options A, C, and D, although important considerations in a healthcare setting, do not directly impact the client’s ability to learn in the same way that severe pain does. Not feeling well, low blood pressure, and anxiety are all factors that can be addressed or managed to facilitate learning, unlike severe pain which can significantly hinder the learning process.

3. When planning to insert a peripheral IV catheter for an older adult client, which of the following actions should the nurse plan to take?

• A. Insert the catheter at a 45° angle
• B. Place the client's arm in a dependent position
• C. Shave excess hair from the insertion site
• D. Initiate IV therapy in the veins of the hand

Correct answer: B

Rationale: Placing the client's arm in a dependent position is the correct action when inserting a peripheral IV catheter for an older adult client. This position helps veins dilate due to gravity, facilitating easier insertion of the IV catheter. Choice A is incorrect because catheters are typically inserted at a lower angle, around 10-30 degrees. Choice C is unnecessary unless excessive hair impedes the insertion process. Choice D is incorrect as veins in the hand are generally smaller and more prone to complications, making them less ideal for IV therapy in older adults.

4. After preparing and lubricating the enema set, what is the correct sequence of steps a nurse should follow when administering a large volume enema to a client?

• A. Administer the enema solution.
• B. Remove the enema tube from the client's rectum.
• C. Wrap the end of the enema tube with a disposable tissue.
• D. Insert the enema tube into the client's rectum.

Correct answer: B

Rationale: The correct sequence for administering a large volume enema is as follows: 1. Insert the enema tube into the rectum, 2. Administer the enema solution, 3. Clamp the tube, 4. Remove the tube, 5. Wrap the end with tissue. Therefore, the nurse should remove the enema tube from the client's rectum after administering the enema solution. Choices A, C, and D are incorrect because the enema tube should be removed from the rectum after the administration of the solution, not before or during the process.

5. A nurse prepares an injection of morphine to administer to a client who reports pain but asks a second nurse to give the injection because another assigned client needs to use a bedpan. Which of the following actions should the second nurse take?

• A. Offer to assist the client who needs the bedpan.
• B. Administer the injection the other nurse prepared.
• C. Prepare another syringe and administer the injection.
• D. Tell the client who needs the bedpan to wait while the nurse gives someone else medication.

Correct answer: C

Rationale: The second nurse should prepare a new syringe and administer the medication to ensure proper and timely pain management. Administering another nurse's medication without preparation could lead to errors. Choice A is not the priority as the medication administration should take precedence. Choice B is not recommended as the second nurse should not administer medication prepared by another nurse. Choice D is inappropriate as patient needs should not be compromised for medication administration to another client.

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