Nursing Elites

1. What must the evening nurse do to facilitate the client's ECT treatment the next morning?

• A. Ensure the patient signs an informed consent form
• B. Administer evening medications
• C. Ensure the patient gets a good night's sleep
• D. Provide dietary restrictions as per ECT protocol

Correct answer: A

Rationale: For electroconvulsive therapy (ECT) treatment, obtaining informed consent is crucial before the procedure. This ensures the patient is aware of the risks, benefits, and alternatives to the treatment. Administering medications, ensuring rest, and dietary restrictions are important but not directly related to the specific requirement of obtaining informed consent for ECT. The correct answer, ensuring the patient signs an informed consent form, is essential to uphold the patient's autonomy and ensure they have the necessary information to make an informed decision about their treatment.

2. A client has a 10% dextrose in water IV solution running. He is scheduled to receive his antiepileptic drug, phenytoin (Dilantin), at this time. The nurse knows that the phenytoin:

• A. is given after the D10W is finished.
• B. should be given at the time it is due in the medication port closest to the client.
• C. can be piggybacked into the D10W solution now.
• D. is incompatible with dextrose solutions.

Correct answer: D

Rationale: Phenytoin is incompatible with dextrose solutions as they will precipitate when mixed together. Therefore, it should not be piggybacked into the D10W solution or given through the same port. Instead, normal saline should be used to flush before and after administering phenytoin to prevent any interaction with the dextrose solution. Delaying the administration of an antiepileptic drug like phenytoin to maintain therapeutic blood levels is not recommended, so it should not be given after the D10W is finished or based on the medication port closest to the client. Choice A is incorrect because administering phenytoin after the D10W is finished is not the correct approach due to the incompatibility with dextrose solutions. Choice B is incorrect as the timing of phenytoin administration should not be based on the medication port closest to the client but on compatibility considerations. Choice C is incorrect as piggybacking phenytoin into the D10W solution is not advisable due to the incompatibility issue.

3. A client is admitted to the floor with vomiting and diarrhea for three days. She is receiving IV fluids at 200cc/hr via pump. A priority action for the nurse would be:

• A. Obtaining Intake and Output.
• B. Frequent lung assessments.
• C. Vital signs every shift.
• D. Monitoring the IV site for infiltration.

Correct answer: D

Rationale: In this scenario, the correct priority action for the nurse would be monitoring the IV site for infiltration. The client is receiving IV fluids at a rapid rate, making it crucial to ensure that the IV site is intact and not causing any complications like infiltration, which can lead to tissue damage. While frequent lung assessments are important for detecting signs of fluid overload, in this case, ensuring the IV site's integrity takes precedence. Obtaining Intake and Output is relevant but not the priority over monitoring the IV site. Vital signs are essential, but given the situation, the immediate concern is the IV site's condition to prevent complications.

4. Which of the following can certain foods like broccoli, oranges, dark greens, and dark yellow vegetables help improve?

• A. Vitamin intake
• B. Body functions
• C. Defense mechanisms
• D. Disease cure

Correct answer: C

Rationale: Certain foods like broccoli, oranges, dark greens, and dark yellow vegetables can help improve defense mechanisms by enhancing the immune system and overall health. While these foods can boost defense mechanisms, they are not a cure for diseases, do not balance body functions, and are not intended to solely supplement vitamin intake, which may be necessary in some cases. Therefore, the correct answer is defense mechanisms as these foods strengthen the body's ability to fight off illnesses and maintain health.

5. A nurse is teaching a client newly diagnosed with Emphysema about the disease process. Which of the following statements best explains the problems associated with emphysema and could be adapted for use in the nurse's discussion with the client?

• A. Hyperactivity of the medium-sized bronchi caused by an inflammatory response leads to wheezing and tightness in the chest.
• B. Larger than normal air spaces and loss of elastic recoil cause air to be trapped in the lung and collapse airways.
• C. Vasodilation, congestion, and mucosal edema cause a chronic cough and sputum production.
• D. Chloride is not being transported properly, producing excess absorption of water and sodium, and thick viscous mucus

Correct answer: B

Rationale: The correct answer is: 'Larger than normal air spaces and loss of elastic recoil cause air to be trapped in the lung and collapse airways.' Emphysema is a breakdown of the elastin and fiber network of the alveoli where the alveoli enlarge or the walls are destroyed. This alveolar destruction leads to the formation of larger-than-normal air spaces. Emphysema is one of a group of pulmonary diseases of a chronic nature characterized by increased resistance to airflow; the entity is part of chronic obstructive pulmonary disease (COPD). Choice A is incorrect because emphysema is not primarily characterized by hyperactivity of the medium-sized bronchi causing wheezing and tightness in the chest. Choice C is incorrect because vasodilation, congestion, and mucosal edema are not the primary mechanisms involved in emphysema, and they do not directly lead to chronic cough and sputum production. Choice D is incorrect because emphysema is not related to chloride transport issues and thick viscous mucus production.

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