Nursing Elites

1. A woman presents with bruises on her face and back in various stages of healing. She states, 'sometimes he just gets so angry.' Which of the following statements is most appropriate as a response from the nurse?

• A. Do you mean your boyfriend?
• B. Do you mean your boyfriend?
• C. No one will ever hurt you again.
• D. Tell me more about what happens when he gets angry.

Correct answer: D

Rationale: The most appropriate response from the nurse is to gather more information by asking the client to elaborate on what occurs when the individual in question gets angry. It is essential for the nurse to understand the situation better before taking any action or making assumptions. Option A and B are repetitive and do not encourage further exploration of the situation. Option C offers a false promise and reassurance that the nurse cannot guarantee, which may not be helpful in addressing the client's needs.

2. The OR nursing staff are preparing a client for a surgical procedure. The anesthesiologist has given the client medications, and the client has entered the induction stage of anesthesia. The nursing staff can expect which of the following symptoms and activities from the client during this time?

• A. Irregular breathing patterns
• B. Minimal heartbeat, dilated pupils
• C. Relaxed muscles, regular breathing, constricted pupils
• D. Euphoria, drowsiness, dizziness

Correct answer: D

Rationale: During the induction stage of anesthesia, the client may exhibit symptoms like euphoria, drowsiness, or dizziness. This stage occurs after the administration of medications by the anesthesiologist and ends when the client loses consciousness. Choice A is incorrect as irregular breathing patterns are not typically associated with the induction stage. Choice B is incorrect as minimal heartbeat and dilated pupils are not commonly observed during this stage. Choice C is incorrect as relaxed muscles, regular breathing, and constricted pupils are not indicative of the induction stage of anesthesia.

3. A nurse is providing dismissal instructions for a child who was admitted for rotavirus. Which of the following statements by the parent indicates the need for further teaching?

• A. I'll start giving him his antibiotics as soon as we get home.
• B. I will call the physician if he becomes dizzy or overly fussy.
• C. He will need to wash his hands a lot to keep this from spreading.
• D. I'll watch to see when he stops having diarrhea stools.

Correct answer: A

Rationale: The correct answer is 'I'll start giving him his antibiotics as soon as we get home.' Rotavirus is a viral illness, and antibiotics are ineffective for its treatment. The parent's statement indicates a need for further teaching as antibiotics are not appropriate for treating rotavirus. Option B is correct as it demonstrates the parent's understanding of when to contact the physician for concerning symptoms. Option C is a correct statement regarding infection control practices. Option D is also correct as monitoring diarrhea stools is essential to track recovery from rotavirus.

4. A client has volunteered to take part in a research study. After participating for two months, he decides that he can no longer tolerate the study and decides to leave. What are the client's rights in this situation?

• A. The client has a right to be released from the study but must reimburse the researchers for charges incurred
• B. The client has a right to be released from the study without any liability
• C. The client has a right to be released from the study but is prohibited from participating in any future studies
• D. The client does not have the right to be released from the study; he must finish his participation

Correct answer: B

Rationale: When a client voluntarily participates in a research study and later decides to withdraw, they have the right to be released from the study without any liability. It is unethical to force a participant to continue in a study against their will as this violates their autonomy and personal rights. Choice A is incorrect as it suggests that the client must reimburse the researchers for charges incurred, which is not typically the case unless agreed upon beforehand. Choice C is incorrect as there is no standard practice prohibiting a participant from future studies just because they withdrew from a current one. Choice D is incorrect because participants always have the right to withdraw from a research study at any time.

5. A nurse is caring for a client who is post-op day #1 after a total hip replacement. Although the client was alert with a normal affect in the morning, by lunchtime, the nurse notes the client is confused, has slurred speech, and is having trouble with her balance. Her blood glucose level is 48 mg/dl. What is the next action of the nurse?

• A. Contact the physician immediately
• B. Administer a bolus of 50 cc of D20W through the IV
• C. Administer 10 units of regular insulin
• D. Give the client 6 oz. of orange juice

Correct answer: D

Rationale: A client with a blood glucose level of 48 mg/dl is experiencing significant hypoglycemia, as manifested by confusion, balance difficulties, and slurred speech. The nurse should work to correct this situation as rapidly as possible. The first measure that can be performed quickly and will have fast results is to give the client something to eat or drink that contains glucose, such as 6 oz. of orange juice. Administering a bolus of D20W through the IV (Choice B) would be too aggressive and could lead to complications in this scenario. Administering regular insulin (Choice C) would further lower the blood glucose level, worsening the client's symptoms. Contacting the physician (Choice A) is important, but immediate intervention to raise the blood glucose level is crucial to address the client's hypoglycemia.

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