Nursing Elites

1. After witnessing a preoperative client sign the surgical consent form, what are the legal implications of the nurse's signature on the client's form as a witness?

• A. The client voluntarily grants permission for the procedure to be done
• B. The surgeon has explained to the client why the surgery is necessary
• C. The client is competent to sign the consent without impairment of judgment
• D. The client understands the risks and benefits associated with the procedure

Correct answer: C

Rationale: The nurse's signature on the consent form signifies that the client is competent to sign the consent without impairment of judgment. This legal implication ensures that the client possesses the necessary capacity to make decisions about their healthcare. Choice A is incorrect because the nurse's signature does not imply the client's voluntary permission for the procedure. Choice B is incorrect as it pertains to the surgeon's responsibility, not the nurse's. Choice D is incorrect as the nurse's signature does not confirm the client's understanding of the risks and benefits associated with the procedure.

2. Which techniques should be used to administer an intradermal (ID) injection for a Mantoux test to screen for tuberculosis (TB)? Select all that apply.

• A. Observe for an intradermal bleed after the antigen is injected
• B. Select an ID site using the volar surface of the forearm
• C. Use a 26 or 27-gauge needle with a length of 1/4 to 5/8 inches on a 1 ml calibrated syringe
• D. Ensure that the needle is inserted into the skin with the bevel up

Correct answer: A

Rationale: Observing for an intradermal bleed after the antigen is injected is a proper technique for an ID injection. This is important to confirm the correct placement of the injection. Choice B is correct because the recommended site for an ID injection for a Mantoux test is the volar surface of the forearm. Choice C is incorrect because the standard needle size for an ID injection is usually 26 or 27 gauge with a length of 1/4 to 5/8 inches, not 25 gauge with a length of 1/2 inch. Choice D is incorrect because the needle should be inserted into the skin with the bevel facing up, not down.

3. A client with major depression who is taking fluoxetine calls the psychiatric clinic reporting being more agitated, irritable, and anxious than usual. Which intervention should the nurse implement?

• A. Tell the client to have a complete blood count (CBC) drawn
• B. Instruct the client to seek medical attention immediately
• C. Encourage them to take the medication at night with a snack
• D. Explain that these are common side effects of the medication

Correct answer: B

Rationale: Increased agitation, irritability, and anxiety can be signs of serotonin syndrome or other serious side effects, not common side effects of fluoxetine. Instructing the client to seek medical attention immediately is crucial to address any potential serious adverse reactions. Option A is unnecessary as a CBC would not address the symptoms described. Option C is not the priority when serious side effects are suspected. Option D is incorrect as these symptoms should not be dismissed as common side effects.

4. The client with diabetes mellitus type 1 has a fruity breath odor. What is the priority nursing action?

• A. Evaluate the client’s intake and output
• B. Measure the client’s capillary blood glucose
• C. Consult with the dietitian about the client’s diet
• D. Apply a pulse oximeter to the client’s finger

Correct answer: B

Rationale: Fruity breath odor in a client with diabetes mellitus type 1 can indicate ketoacidosis, a serious complication. Measuring the client’s capillary blood glucose is the priority nursing action in this scenario as it helps diagnose and manage the condition effectively. Evaluating intake and output may be important for overall assessment but not the priority when dealing with a potential emergency like ketoacidosis. Consulting with a dietitian about the client’s diet is important for long-term management but not the immediate priority. Applying a pulse oximeter is not relevant to addressing the fruity breath odor and suspected ketoacidosis.

5. The healthcare provider is evaluating a client for potential dehydration. Which assessment finding is most indicative of fluid volume deficit?

• A. Moist mucous membranes
• B. Increased urine output
• C. Decreased skin turgor
• D. Elevated blood pressure

Correct answer: C

Rationale: Corrected Rationale: Decreased skin turgor is a classic sign of dehydration. When someone is dehydrated, the skin loses its elasticity and becomes less turgid. This change is easily assessed by gently pinching and pulling up the skin on the back of the hand or forearm. If the skin remains elevated or tents rather than quickly returning to its normal position, it indicates dehydration. Moist mucous membranes (Choice A) are actually a sign of adequate hydration. Increased urine output (Choice B) can be a sign of dehydration, but decreased skin turgor is a more specific indicator. Elevated blood pressure (Choice D) is not typically associated with fluid volume deficit and may indicate other health issues.

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