Nursing Elites

1. A client with a history of renal failure is being cared for by a nurse. Which of the following should the nurse monitor?

• A. Fluid intake
• B. Electrolyte levels
• C. Blood pressure
• D. Both B and C

Correct answer: D

Rationale: Clients with renal failure are at risk for electrolyte imbalances and hypertension. Monitoring electrolyte levels is crucial because renal failure can lead to imbalances in sodium, potassium, and other electrolytes. Blood pressure monitoring is essential as hypertension is a common complication of renal failure. Therefore, both electrolyte levels and blood pressure should be closely monitored to detect and manage any abnormalities. Fluid intake, while important, is not specific to renal failure monitoring and is not the priority in this case.

2. A nurse is preparing to administer a measles, mumps, rubella (MMR) immunization to a child. Which is a contraindication for this vaccine?

• A. Recent blood transfusion
• B. Allergy to penicillin
• C. Minor acute illness
• D. Low-grade fever

Correct answer: A

Rationale: The correct answer is A: Recent blood transfusion. A recent blood transfusion can interfere with the effectiveness of the MMR vaccine, making it a contraindication. Choice B, allergy to penicillin, is not a contraindication for the MMR vaccine. Choice C, minor acute illness, is not a contraindication unless the child has a moderate to severe illness. Choice D, low-grade fever, is not a contraindication as long as the child does not have a moderate to severe febrile illness.

3. A provider has written a do not resuscitate (DNR) order for a client who is comatose and does not have advance directives. A member of the client’s family says, 'I wonder when the doctor will tell us what’s going on.' Which of the following actions should the nurse take first?

• A. Request that the provider provide more information to the family.
• B. Refer the family to a support group for grief counseling.
• C. Offer to answer questions that family members have.
• D. Ask the family what the provider has discussed with them.

Correct answer: D

Rationale: The correct action for the nurse to take first is to ask the family what the provider has discussed with them. This allows the nurse to clarify any misunderstandings and ensures that the family is fully informed before providing further information. Option A is not the best choice because it assumes the need for more information without first understanding what has already been communicated. Option B is premature as the family may not be ready for grief counseling at this stage. Option C, although a good general practice, is not the most appropriate immediate action in this situation where clarifying existing information is crucial.

4. A healthcare professional is assessing a client for signs of hypoglycemia. Which of the following findings should the healthcare professional look for?

• A. Increased thirst
• B. Fatigue
• C. Weight gain
• D. Elevated blood pressure

Correct answer: B

Rationale: The correct answer is B: Fatigue. Fatigue, along with symptoms like shakiness and irritability, are common signs of hypoglycemia. Increased thirst (Choice A) is more indicative of hyperglycemia. Weight gain (Choice C) is not typically associated with hypoglycemia. Elevated blood pressure (Choice D) is not a common sign of hypoglycemia.

5. A hospice nurse is providing teaching to a patient who has a new diagnosis of a terminal illness and her family. Which statement should the nurse include in the teaching?

• A. Hospice care will help provide rehabilitation for the patient.
• B. Hospice care focuses on extending life by any means necessary.
• C. Hospice care will help the patient transition to nursing care.
• D. Hospice care continues to help families with grief after a death occurs.

Correct answer: D

Rationale: The correct statement that the nurse should include in the teaching is option D: 'Hospice care continues to help families with grief after a death occurs.' Hospice care not only focuses on providing comfort care for terminal patients but also offers bereavement support to families after the patient's death. Choices A, B, and C are incorrect. Option A is incorrect because hospice care does not provide rehabilitation for the patient; its focus is on comfort and quality of life. Option B is incorrect because hospice care does not aim to extend life but rather to provide quality end-of-life care. Option C is incorrect because hospice care does not transition patients to nursing care; it provides care focused on comfort and symptom management in the patient's preferred setting.

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