Nursing Elites

1. After a left heart catheterization (LHC), a client complains of severe foot pain on the side of the femoral stick. The nurse notes pulselessness, pallor, and a cold extremity. What should the nurse's next action be?

• A. Administer an anticoagulant.
• B. Warm the room and re-assess.
• C. Increase IV fluids.
• D. Notify the physician stat.

Correct answer: D

Rationale: The correct action for the nurse to take next is to notify the physician immediately (stat). The client's symptoms of foot pain, pulselessness, pallor, and cold extremity suggest a potential vascular complication, such as arterial occlusion. Prompt notification of the physician is crucial as this condition requires urgent intervention to restore blood flow and prevent tissue damage. Administering an anticoagulant (Choice A) without physician evaluation could be harmful as the underlying cause needs to be determined first. Warming the room and re-assessing (Choice B) may delay necessary treatment. Increasing IV fluids (Choice C) is unlikely to address the urgent vascular issue indicated by the symptoms described.

2. A client with sleep apnea has been ordered a CPAP machine. Which action could the RN delegate to a nursing assistant?

• A. Reminding the client to apply the CPAP at bedtime
• B. Obtaining every three-hour oxygen saturation levels
• C. Teaching the client how to turn on the CPAP machine
• D. Assessing for fatigue or depression caused by poor sleep

Correct answer: A

Rationale: The correct answer is reminding the client to apply the CPAP at bedtime. This task can be safely delegated to a nursing assistant as it involves a simple and routine reminder. Option B, obtaining oxygen saturation levels, requires a higher level of training and interpretation of results, making it more appropriate for an RN. Option C, teaching the client how to turn on the CPAP machine, involves educating the client and ensuring proper use of medical equipment, which is within the RN's scope of practice. Option D, assessing for fatigue or depression, requires a comprehensive evaluation that involves interpreting symptoms and identifying underlying causes, making it more suitable for an RN to address.

3. The client is admitted with a period of unobserved loss of consciousness and now has an EEG scheduled this morning. What should the nurse implement?

• A. Keep NPO and hold medication.
• B. Hold sedatives, but allow the client to have breakfast and give other medicines.
• C. Administer medications, but hold anticonvulsants.
• D. Give additional fluids and some caffeine prior to the test.

Correct answer: C

Rationale: Prior to an EEG, it is essential for the client to eat to prevent a drop in blood sugar levels. The nurse should hold sedatives but allow the client to have breakfast and administer other necessary medications. Holding sedatives is crucial to ensure accurate EEG results, while providing breakfast helps maintain stable blood sugar levels. Administering other medications, excluding sedatives, is important for the client's overall care. Choices A, C, and D are incorrect because keeping the client NPO and holding medications, administering medications but holding anticonvulsants, and giving additional fluids and caffeine are not appropriate actions before an EEG.

4. The client diagnosed with end-stage liver disease has completed an advance directive and a do-not-resuscitate (DNR) document and wishes to receive palliative care. Which of the following would correspond to the client's wish for comfort care?

• A. Positioning frequently to prevent skin breakdown and providing pain management and other comfort measures
• B. Carrying out vigorous resuscitation efforts if the client were to stop breathing, but no resuscitation if the heart stops beating
• C. Providing intravenous fluids when the client becomes dehydrated
• D. Providing total parenteral nutrition (TPN) if the client is not able to eat

Correct answer: A

Rationale: Palliative care includes measures to prevent skin breakdown, pain management, and management of other symptoms that cause discomfort, as well as encouraging contact with family and friends. A DNR request precludes all resuscitative efforts related to respiratory or cardiac arrest, making choice B incorrect. Dehydration is a natural part of the dying process, so providing intravenous fluids as in choice C would not align with the client's wish for comfort care. Total parenteral nutrition (TPN) as in choice D is an invasive procedure meant to prolong life and is not part of palliative care, which focuses on improving quality of life rather than extending it.

5. Teaching about the importance of avoiding foods high in potassium is most crucial for which client?

• A. a client receiving diuretic therapy
• B. a client with an ileostomy
• C. a client with metabolic alkalosis
• D. a client with renal disease

Correct answer: D

Rationale: Clients with renal disease are prone to hyperkalemia due to impaired kidney function, making it crucial for them to avoid foods high in potassium to prevent further complications. Choices A, B, and C are incorrect because clients receiving diuretic therapy, with an ileostomy, or with metabolic alkalosis are at risk of hypokalemia. These individuals should actually consume foods high in potassium to replenish the electrolyte lost through diuresis, ileostomy output, or metabolic alkalosis.

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