Nursing Elites

1. A client has been administered ketamine by a physician in preparation for general anesthesia. Which of the following side effects should the nurse monitor for in this client?

• A. Delirium
• B. Muscle rigidity
• C. Hypotension
• D. Pinpoint rash

Correct answer: A

Rationale: Ketamine is an anesthetic that induces dissociation and lack of awareness in a client. It can be used before general anesthesia or during short procedures for sedation. Ketamine may lead to side effects such as delirium, hallucinations, hypertension, and respiratory depression. Therefore, the nurse should monitor the client for delirium, as it is a potential side effect associated with ketamine use. Muscle rigidity, hypotension, and pinpoint rash are not typically attributed to ketamine administration and are less likely to occur in this scenario.

2. Select the age group that is coupled with an infectious disease that is most common in this age group.

• A. Infants: High bilirubin
• B. Pre-School and School Age Children: Shingles
• C. Young Adults and Teenagers: Sexually transmitted diseases
• D. The Elderly: Malaria

Correct answer: C

Rationale: Young adults and teenagers are at the highest risk for sexually transmitted diseases due to their sexual activity. High bilirubin is a laboratory finding related to jaundice and not an infectious disease. Shingles is more common in the elderly population, not in pre-school and school-age children. Malaria is not most common in the elderly; it is prevalent in regions with specific mosquito vectors. Therefore, the correct answer is that young adults and teenagers are most commonly associated with sexually transmitted diseases.

3. A client is admitted to a nursing unit with a remittent fever. Which statement best describes this pattern of fever?

• A. A fever that spikes and then lowers without returning to normal
• B. A fever that lasts 2 days followed by normal temperature for 2 days, followed by fever again
• C. A fever that lasts 2 days followed by normal temperature for 12 hours, followed by fever again
• D. A persistent fever that has lasted over 24 hours

Correct answer: A

Rationale: A remittent fever is characterized by temperature fluctuations where the fever spikes and then lowers but does not return to normal temperature. Option A best describes this pattern of fever. Option B describes a pattern of fever known as a biphasic fever, where the fever alternates between days of fever and normal temperature. Option C describes a pattern of fever that is more indicative of an intermittent fever, where the fever lasts for a specific duration followed by an interval of normal temperature. Option D does not accurately describe a remittent fever, as it suggests a persistent fever that has lasted over 24 hours, which is not specific to the remittent pattern.

4. What is a key principle of patient teaching that must take place to ensure patient safety?

• A. Family members should be present
• B. Teaching must be documented
• C. Understanding must be confirmed
• D. Teaching should be provided by multiple staff members

Correct answer: C

Rationale: A key principle of patient teaching that ensures patient safety is the confirmation of understanding. To ensure patient safety, it is crucial to confirm that the patient comprehends the information provided. This confirmation can be achieved by having the patient repeat back the information or demonstrate understanding through return demonstration. Documenting the patient's understanding is essential to track the effectiveness of the teaching session and ensure that the patient is equipped with the necessary knowledge for their safety. Family members being present or having multiple staff members provide teaching may be beneficial in certain situations, but the primary focus should be on confirming the patient's understanding to enhance safety and promote effective learning.

5. A 39-year-old woman presents for treatment of excessive vaginal bleeding after giving birth to twins one week ago. Which nursing diagnosis is most appropriate in this situation?

• A. Knowledge Deficit related to post-partum blood loss
• B. Self-Care Deficit related to post-partum neglect
• C. Fluid Volume Deficit related to post-partum hemorrhage
• D. Body Image Disturbance related to body changes after delivery

Correct answer: C

Rationale: The correct nursing diagnosis in this situation is 'Fluid Volume Deficit related to post-partum hemorrhage.' Post-partum hemorrhage can lead to excessive bleeding, putting the client at risk of fluid volume deficit due to the loss of blood volume. This diagnosis is most appropriate as it addresses the immediate concern of fluid loss. 'Knowledge Deficit related to post-partum blood loss' (Choice A) is incorrect as the priority in this case is addressing the physical issue of fluid volume deficit rather than knowledge deficit. 'Self-Care Deficit related to post-partum neglect' (Choice B) is not relevant to the situation described. 'Body Image Disturbance related to body changes after delivery' (Choice D) is not the most appropriate nursing diagnosis in this context where the primary concern is fluid volume deficit due to post-partum hemorrhage.

Similar Questions