Nursing Elites

1. In an emergency situation where a client is unconscious and requires immediate surgery, what action is necessary with regard to informed consent?

• A. The healthcare team will proceed with the surgery as consent is not needed in emergencies.
• B. The healthcare team will wait until the client's family can be contacted for consent.
• C. The healthcare team will contact the hospital clergy to provide informed consent.
• D. The healthcare team will obtain consent from the client's legal guardian before proceeding.

Correct answer: A

Rationale: In emergency situations where obtaining consent is not possible due to the client's condition, healthcare providers are allowed to perform life-saving procedures without informed consent. It is assumed that the client would want to receive necessary treatment to save their life. Therefore, the correct action is for the healthcare team to proceed with the surgery as consent is not needed. Waiting to contact the client's family for consent can delay life-saving treatment, risking the client's life. Contacting the hospital clergy for consent is unnecessary and can cause further delays. Obtaining consent from the client's legal guardian is not feasible in this critical situation and may lead to a delay in providing essential care.

2. Several passengers aboard an airliner suddenly become weak and suffer breathing difficulty. The diagnosis is likely to be:

• A. Outbreak of Asian flu.
• B. Chemical exposure.
• C. Bacterial pneumonia.
• D. Allergic reaction.

Correct answer: B

Rationale: The most likely cause of groups of individuals suddenly experiencing similar signs of illness all at once is a chemical exposure. In this scenario, considering the sudden onset of symptoms in multiple passengers on an airliner, the symptoms are more indicative of a chemical exposure rather than Asian flu, bacterial pneumonia, or an allergic reaction. Asian flu, bacterial pneumonia, and allergic reactions do not typically manifest in a way that would affect a group of individuals simultaneously. Therefore, the correct diagnosis in this case is likely to be a chemical exposure.

3. The nurse is preparing task assignments for the day. Which task should the nurse assign to a nursing assistant?

• A. Monitoring for bleeding for a client who has just undergone cardiac catheterization
• B. Assisting a client who is getting up to ambulate for the first time after surgery
• C. Providing oral care to an unconscious client who requires oral care
• D. Completing the preoperative checklist for a client scheduled for a liver biopsy

Correct answer: C

Rationale: When delegating tasks, the nurse must consider the state nursing practice act guidelines and job descriptions. Providing oral care to an unconscious client is a task suitable for delegation to a nursing assistant. The nurse should give clear instructions on adapting the procedure for the client's needs and the signs of complications to watch for. Monitoring for bleeding after cardiac catheterization necessitates immediate nursing assessment, which requires critical thinking and intervention that exceeds a nursing assistant's scope of practice. Assisting a client with ambulation post-surgery carries the risk of orthostatic hypotension and should be performed by a licensed nurse. Completing a preoperative checklist for a client scheduled for a liver biopsy involves critical assessment and preparation that are within the nurse's scope of practice.

4. Which of the following statements by an adult child of a client with late-stage Alzheimer's disease indicates a need for further teaching by the nurse?

• A. "I should provide a regular schedule for toileting."?
• B. "I should talk to my father less because he can't communicate."?
• C. "I should give my father oral care after every meal and bedtime."?
• D. "I should assist my father with eating and drinking."?

Correct answer: B

Rationale: In late-stage Alzheimer's disease, although verbal communication may be challenging or limited, it is essential to maintain communication through talking and non-verbal cues like touching. Limiting communication can lead to feelings of isolation and worsen the emotional well-being of the individual. Choices A, C, and D reflect appropriate care strategies by addressing toileting needs, oral care, and assistance with eating and drinking, which are crucial aspects of caregiving for a client with late-stage Alzheimer's disease.

5. A client is on a clear liquid diet. She drinks half of a 12-ounce juice, 4 ounces of soup, and has a 6-ounce JELLO®. How many milliliters of fluid did the patient ingest?

• A. 440 ml
• B. 480 ml
• C. 220 ml
• D. 660 ml

Correct answer: B

Rationale: To calculate the total amount of fluid ingested, convert the ounces to milliliters. Given that 1 ounce is equal to 30 ml, the breakdown is as follows: Juice (6 ounces): 6 x 30 = 180 ml. Soup (4 ounces): 4 x 30 = 120 ml. JELLO® (6 ounces): 6 x 30 = 180 ml. Adding these together: 180 ml (juice) + 120 ml (soup) + 180 ml (JELLO®) = 480 ml. Therefore, the patient ingested a total of 480 ml of fluid. It's important to note that gelatin, ice cream, and similar items that are liquid at room temperature should be considered as fluids. Choice A, 440 ml, is incorrect as it does not account for the correct calculation. Choice C, 220 ml, is incorrect as it is significantly lower than the correct total. Choice D, 660 ml, is incorrect as it overestimates the total fluid intake.

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