Nursing Elites

1. A nurse is caring for a client who requests information about advance directives. Which of the following responses should the nurse make?

• A. It's a living will outlining your funeral wishes
• B. It's a document that allows you to donate organs
• C. It includes end-of-life care instructions
• D. It provides legal guardianship rights

Correct answer: C

Rationale: The correct response is C: 'It includes end-of-life care instructions.' An advance directive is a legal document that outlines a client's preferences for medical treatment and end-of-life care in case they are unable to communicate. Choice A is incorrect because an advance directive focuses on healthcare decisions, not funeral arrangements. Choice B is incorrect as organ donation is a separate process from advance directives. Choice D is incorrect as advance directives do not provide legal guardianship rights, but rather specify healthcare wishes.

2. A nurse is caring for a client who has been diagnosed with hyperkalemia. Which of the following findings should the nurse expect?

• A. Muscle weakness
• B. Nausea
• C. Increased thirst
• D. Restlessness

Correct answer: A

Rationale: Muscle weakness is a characteristic finding in hyperkalemia. High levels of potassium can affect the normal function of muscles, leading to weakness. Nausea and increased thirst are not typically associated with hyperkalemia. Restlessness is more commonly seen in conditions such as hypoxia or anxiety, not specifically in hyperkalemia.

3. A nurse is preparing to administer purified protein derivative (PPD) to a client who has suspected tuberculosis. Which of the following actions should the nurse plan to take?

• A. Ensure the injection produces a wheal on the skin
• B. Administer the injection in the client's thigh
• C. Use an intradermal needle for the injection
• D. Avoid touching the site after injection

Correct answer: A

Rationale: The correct answer is A: Ensure the injection produces a wheal on the skin. A wheal indicates that the PPD has been administered correctly, allowing for the proper interpretation of results. Administering the injection in the client's thigh (choice B) is not the recommended site for PPD administration; it should be administered intradermally. Using an 18-gauge needle (choice C) is unnecessary and not the standard practice for PPD administration as a smaller gauge needle is preferred for intradermal injections. Massaging the site after injection (choice D) can lead to inaccurate results by dispersing the solution, so it is important to avoid touching the site after the injection to prevent altering the test results.

4. What is the recommended intervention for a patient experiencing severe hypoglycemia?

• A. Administer glucagon
• B. Provide a source of glucose
• C. Monitor blood sugar
• D. Assess vital signs

Correct answer: A

Rationale: Administering glucagon is the recommended intervention for severe hypoglycemia, especially when the patient is unconscious or unable to consume oral glucose. Glucagon helps increase blood glucose levels rapidly by stimulating the release of stored glucose from the liver. Providing a source of glucose (Choice B) can be challenging if the patient is unable to swallow or unconscious, making glucagon a more effective option. Monitoring blood sugar levels (Choice C) and assessing vital signs (Choice D) are important aspects of managing hypoglycemia but are not the immediate intervention for severe cases where prompt elevation of blood glucose levels is necessary.

5. A nurse is instructing a group of nursing students about the responsibilities involved with organ donation and procurement. When the nurse explains that all clients waiting for a kidney transplant have to meet the same qualifications, the students should understand that this aspect of care delivery is an example of which ethical principle?

• A. Fidelity
• B. Autonomy
• C. Justice
• D. Non-maleficence

Correct answer: C

Rationale: The correct answer is C: Justice. Justice in healthcare ethics refers to fairness and equality in the distribution of resources and treatments. In this scenario, ensuring that all clients waiting for a kidney transplant meet the same qualifications demonstrates the ethical principle of justice by providing equal opportunities for all candidates. Choice A, fidelity, pertains to keeping promises and being faithful to agreements, which is not the primary ethical principle at play in this situation. Autonomy, choice B, relates to respecting a patient's right to make their own decisions, which is not directly applicable in the context of organ transplant qualifications. Non-maleficence, choice D, refers to the principle of doing no harm, which is important but not the primary ethical principle highlighted in this scenario.

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