Nursing Elites

1. A 50-milliliter (ml) bolus of normal saline fluid is ordered by the physician. The physician wants it to infuse in 30 minutes. The nurse should set the pump rate at:

• A. 100 ml per hour for one hour.
• B. 60 ml per hour for one-half hour
• C. 120 ml per hour for one hour.
• D. 50 ml per hour for one hour.

Correct answer: A

Rationale: To infuse a 50 ml bolus in 30 minutes, the rate should be calculated as follows: 50 ml / 30 min = 100 ml per hour. Therefore, the correct answer is to set the pump rate at 100 ml per hour for one hour. Choice A is the correct rate based on the calculation. Choices B, C, and D all provide incorrect rates that do not match the physician's order. Choice B would only deliver 30 ml in 30 minutes, not the ordered 50 ml. Choice C would deliver 120 ml in one hour, which is 20 ml more than ordered. Choice D would only provide 25 ml over 30 minutes, not the full 50 ml prescribed.

2. A client reports that he is 'talking to the voices.' The nurse observes this behavior. The nurse's next action should be:

• A. touching the client to help him return to reality
• B. leaving the client alone until reality returns
• C. asking the client to describe what is happening
• D. telling the client there are no voices

Correct answer: A

Rationale: When a client reports talking to voices, the nurse should engage in a gentle touch to help the client return to reality. It is important for the nurse to acknowledge the client's experience and attempt to redirect them gently. Touch can provide grounding and connection. Asking the client to describe what is happening can be overwhelming and might exacerbate the situation. Leaving the client alone may not be safe or therapeutic as the client may need support. Telling the client there are no voices denies their reality and is not helpful in managing their experience.

3. When teaching clients with a diagnosis of Schizophrenia nearing discharge from a residential care facility, what is an essential topic to include?

• A. pathophysiology of the disease and expected symptoms.
• B. how to recognize and manage symptoms of relapse.
• C. the need to take extra medication when feeling stressed.
• D. the importance of contact with follow-up care daily.

Correct answer: B

Rationale: When educating clients with Schizophrenia nearing discharge, it is crucial to focus on teaching them how to recognize and manage symptoms of relapse. Clients are usually aware of these symptoms, such as feeling anxious and overwhelmed, before the onset of psychosis. This early stage is vital for intervention, which involves finding a safe environment, seeking help, avoiding stressors, and reducing stimuli. Understanding and managing relapse symptoms empower clients to take proactive steps in their care. Choices A and C are not as immediate and practical as recognizing symptoms of relapse for client safety and well-being. While contact with follow-up care is important, it is not as urgent and specific as knowing how to manage relapse symptoms for immediate intervention.

4. A client with a diagnosis of Schizophrenia has been released from an acute care setting. The client had a prolonged recovery from relapse. One of the parents says to the discharge nurse, 'I do not understand what is going on. The hospital said she was better, but all she does is sit around all day and smoke. We cannot get her to go to the vocational training you arranged.' The nurse recognizes that more teaching is needed about

• A. the pathophysiology and behavioral manifestations of schizophrenia.
• B. support groups that can help the parents cope with their frustration.
• C. the prolonged recovery time and side effects of medications to prevent relapse.
• D. motivational techniques that are effective in engaging clients with schizophrenia.

Correct answer: C

Rationale: The nurse conducting discharge teaching must emphasize the extended recovery process and the potential side effects of medications used to prevent relapse in individuals with schizophrenia. In this scenario, it is crucial for the parents to understand that the client's behavior may be influenced by the medication's sedative qualities and the time required for full recovery. While support groups can assist caregivers in coping with their emotions and providing better care, the priority here is educating on the recovery process and medication effects. Motivational techniques are beneficial but may not be the immediate focus in this situation.

5. Which client can best be assigned to the newly licensed practical nurse?

• A. The client receiving chemotherapy
• B. The client post-coronary bypass
• C. The client with a TURP
• D. The client with diverticulitis

Correct answer: D

Rationale: The best client to assign to the newly licensed nurse is the most stable client. In this case, the client with diverticulitis is the most stable among the options provided. Clients receiving chemotherapy and those post-coronary bypass require specialized care and attention, making them unsuitable for a newly licensed nurse. The client with a TURP may be at risk of bleeding, needing a nurse experienced in managing such complications. Therefore, the client with diverticulitis is the most appropriate choice for the newly licensed practical nurse.

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