Nursing Elites

1. After informing an older client that an IV line needs to be inserted, the client becomes very apprehensive, loudly expressing a dislike for all healthcare providers and nurses. How should the nurse respond?

• A. Ask the client to remain quiet so the procedure can be performed safely.
• B. Concentrate on completing the insertion as efficiently as possible.
• C. Calmly reassure the client that the discomfort will be temporary.
• D. Tell the client a joke as a means of distraction from the procedure.

Correct answer: C

Rationale: In this situation, the nurse should respond by calmly reassuring the client that the discomfort from the IV insertion will be temporary. By providing reassurance and addressing the client's concerns, the nurse can help reduce the client's apprehension and create a more supportive environment for the procedure.

2. A CVA (stroke) patient goes into respiratory distress and is placed on a ventilator. The client’s daughter arrives with a durable power of attorney and a living will that indicates there should be no extraordinary life-saving measures. What action should the nurse take?

• A. Refer to the risk manager
• B. Notify the healthcare provider
• C. Discontinue the ventilator
• D. Review the medical record

Correct answer: B

Rationale: In this situation, the nurse should notify the healthcare provider. The healthcare provider needs to be informed to review the legal documents provided by the patient's daughter, such as the durable power of attorney and living will, which specify the patient's wishes regarding life-saving measures. The healthcare provider will be responsible for making the appropriate decision based on the legal documents and the patient's current condition. Referring to the risk manager (choice A) is not necessary as the issue at hand pertains to the patient's medical care. Discontinuing the ventilator (choice C) without healthcare provider input could go against the patient's wishes and legal documents. Reviewing the medical record (choice D) may not provide immediate guidance on the current situation and the patient's preferences regarding life-saving measures.

3. A client is admitted with a diagnosis of diabetic ketoacidosis (DKA). Which assessment finding should the nurse anticipate?

• A. Oliguria.
• B. Kussmaul respirations.
• C. Fruity odor on the breath.
• D. Blood glucose level of 250 mg/dL.

Correct answer: B

Rationale: Kussmaul respirations (B) are a deep and labored breathing pattern associated with diabetic ketoacidosis (DKA) and are expected in this condition. While oliguria (A), fruity odor on the breath (C), and elevated blood glucose level (D) are also signs of DKA, Kussmaul respirations are more specific and critical to the condition, indicating severe metabolic acidosis.

4. The healthcare provider is aware that malnutrition is a common problem among clients served by a community health clinic for the homeless. Which laboratory value is the most reliable indicator of chronic protein malnutrition?

• A. Low serum albumin level
• B. Low serum transferrin level
• C. High hemoglobin level
• D. High cholesterol level

Correct answer: A

Rationale: A low serum albumin level is the most reliable indicator of chronic protein malnutrition. Serum albumin levels reflect long-term protein status, and a significantly lowered level usually indicates ongoing protein deficiency. Other laboratory values, such as serum transferrin, hemoglobin, or cholesterol levels, may be affected by various factors and conditions, but serum albumin is a more specific marker for chronic protein malnutrition.

5. A client with a history of myocardial infarction (MI) is admitted with chest pain. Which laboratory test should the nurse expect to be ordered to determine if the client is experiencing another MI?

• A. Troponin
• B. Myoglobin
• C. CK-MB
• D. C-reactive protein

Correct answer: A

Rationale: Troponin is the most specific and sensitive laboratory test for detecting myocardial infarction (MI). It is released when there is damage to the heart muscle, making it a valuable marker for diagnosing another MI. Myoglobin and CK-MB can also be elevated in MI, but troponin is preferred due to its higher specificity. C-reactive protein is a marker of inflammation and not specific to MI.

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