Nursing Elites

1. A nurse is providing an in-service about client rights for a group of nurses. Which of the following statements should the nurse include in the service?

• A. A nurse can disclose information to a family member with the client's permission
• B. A nurse can apply restraints on an as-needed basis
• C. A nurse can administer medications without consent to a client as part of a research study
• D. A nurse is responsible for informing clients about treatment options

Correct answer: A

Rationale: The correct statement to include in the in-service about client rights is that a nurse can disclose information to a family member with the client's permission. This respects the client's autonomy and privacy. Choice B is incorrect because restraints should only be applied based on a specific assessment and order, not on an as-needed basis. Choice C is incorrect as administering medications without consent is a violation of ethical principles and legal standards. Choice D is incorrect because while nurses should educate clients about treatment options, the ultimate decision lies with the client after being informed.

2. Which of the following nursing interventions should be taken for a client who complains of nausea and vomits one hour after taking his glyburide (DiaBeta)?

• A. Administer glyburide again
• B. Administer subcutaneous insulin and monitor blood glucose
• C. Monitor blood glucose closely, and look for signs of hypoglycemia
• D. Monitor blood glucose and assess for signs of hyperglycemia

Correct answer: C

Rationale: After a client complains of nausea and vomits one hour after taking glyburide, the priority nursing intervention should be to monitor blood glucose closely and look for signs of hypoglycemia. Vomiting could indicate that the glyburide was not properly absorbed, potentially leading to hypoglycemia. Administering glyburide again (Choice A) could worsen hypoglycemia. Administering subcutaneous insulin (Choice B) is not appropriate without assessing the blood glucose first. Monitoring for signs of hyperglycemia (Choice D) is not the immediate concern in this situation.

3. A nurse working on a med-surg unit is managing the care of four clients. The nurse should schedule an interdisciplinary conference for which of the following clients?

• A. A client who is at risk for pressure ulcers and has an albumin level of 4.2 g/dL
• B. A client with type 1 DM who uses an insulin pump
• C. A client who is receiving heparin and has an aPTT of 34 seconds
• D. A client with orthostatic hypotension receiving IV fluids

Correct answer: C

Rationale: The nurse should schedule an interdisciplinary conference for a client who is receiving heparin and has an aPTT of 34 seconds to ensure comprehensive care coordination. In this case, the need for a conference may be to discuss potential adjustments in heparin therapy, monitor for adverse effects, or ensure proper anticoagulation levels. Choices A, B, and D do not specifically indicate the need for interdisciplinary collaboration related to the client's condition or treatment. Therefore, they are not the priority for scheduling an interdisciplinary conference.

4. What is idiopathic thrombocytopenia purpura?

• A. Highly similar to disseminated intravascular coagulation (DIC).
• B. Caused by the overproduction of platelets.
• C. A bleeding disorder that is characterized by too few platelets.
• D. Treated with immune system-boosting medications.

Correct answer: C

Rationale: Idiopathic thrombocytopenic purpura is a bleeding disorder characterized by a low number of platelets in the blood. This condition is not highly similar to disseminated intravascular coagulation (DIC), which involves abnormal clotting throughout the body (coagulation), leading to depletion of platelets. Choice B is incorrect because idiopathic thrombocytopenic purpura is actually characterized by a decrease in platelet count, not an overproduction. While immune system-boosting medications may be used in some cases, the primary treatment for idiopathic thrombocytopenic purpura focuses on increasing platelet counts or managing symptoms.

5. Ben injects his insulin as prescribed, but then gets busy and forgets to eat. What will the best assessment of the nurse reveal?

• A. The client will be very thirsty.
• B. The client will complain of nausea.
• C. The client will need to urinate.
• D. The client will have moist skin.

Correct answer: D

Rationale: The correct answer is D. In this scenario, since Ben took his insulin but forgot to eat, he is at risk of developing hypoglycemia. Moist skin is a sign of hypoglycemia, which can occur when blood sugar levels drop too low. Thirstiness (choice A) is more commonly associated with hyperglycemia (high blood sugar levels). Nausea (choice B) and frequent urination (choice C) are not typical immediate signs of hypoglycemia caused by missing a meal after insulin administration.

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