Nursing Elites

1. An unresponsive male victim of a diving accident is brought to the emergency department where immediate surgery is required to save his life. No family members are available. What action should the nurse take first?

• A. Ask the friend to sign an informed consent.
• B. Notify the unit manager that a court order is needed.
• C. Continue providing life support until a guardian is found.
• D. Proceed with surgery preparation without consent.

Correct answer: D

Rationale: In emergency situations where immediate surgery is required to save a patient's life and no family members are available, consent can be waived to proceed with necessary interventions. The priority in this scenario is to proceed with surgery preparation without waiting for consent, as any delay could jeopardize the patient's life. Asking the friend to sign informed consent or notifying the unit manager for a court order would cause unnecessary delays, which are not advisable in this critical situation. Continuing life support until a guardian is found is not the most appropriate action when immediate surgical intervention is necessary.

2. A client with deep vein thrombosis (DVT) is prescribed warfarin. What teaching should the nurse provide to the client?

• A. Avoid leafy green vegetables while taking warfarin.
• B. Report any unusual bruising or bleeding.
• C. Take warfarin at the same time every day.
• D. Avoid alcohol consumption while on warfarin.

Correct answer: D

Rationale: The correct answer is D: 'Avoid alcohol consumption while on warfarin.' Alcohol can increase the risk of bleeding when taken with warfarin, so it should be avoided. Choice A is incorrect as leafy green vegetables contain vitamin K, which can interfere with the anticoagulant effects of warfarin. Choice B is important but not directly related to alcohol consumption. Choice C is a general instruction for medication adherence but not specifically related to the interaction with alcohol.

3. The nurse is teaching a client with asthma to use a peak expiratory flow rate (PEFR) meter to manage asthma at home. The nurse knows the client understands the proper use of the meter when the client:

• A. Inhales as rapidly as possible when using the meter
• B. Records the highest of three readings
• C. Uses the meter after taking a bronchodilator
• D. Blows out forcefully into the meter after taking a deep breath

Correct answer: B

Rationale: The correct answer is B: 'Records the highest of three readings.' When using a peak expiratory flow rate (PEFR) meter, the client should record the highest of three readings to ensure an accurate measurement of their peak expiratory flow rate. Inhaling rapidly, using the meter after taking a bronchodilator, or blowing out forcefully into the meter after a deep breath are not correct techniques for using a PEFR meter and may lead to inaccurate results.

4. A young woman with multiple sclerosis just received several immunizations in preparation for moving into a college dormitory. Two days later, she reports to the nurse that she is experiencing increasing fatigue and visual problems. What teaching should the nurse provide?

• A. Immunizations can trigger a relapse of the disease, so get plenty of extra rest
• B. Visual problems are unrelated to the recent immunizations
• C. Increase fluid intake to reduce symptoms of fatigue
• D. Consult the healthcare provider immediately for steroid therapy

Correct answer: A

Rationale: Immunizations can sometimes trigger relapses in multiple sclerosis due to the activation of the immune system. Extra rest can help manage these symptoms. Choice B is incorrect because visual problems can be associated with the immune response triggered by immunizations in individuals with multiple sclerosis. While increasing fluid intake is generally good advice, in this case, the nurse should focus on explaining the possible connection between the immunizations and the symptoms experienced. Choice D is not the immediate course of action; educating the patient on the potential link between immunizations and symptom exacerbation is more appropriate at this stage.

5. A child is admitted with bacterial meningitis. What assessment finding should the nurse monitor most closely?

• A. Monitor the client’s skin for rash and lesions.
• B. Monitor for signs of increased intracranial pressure.
• C. Monitor the client’s blood pressure closely.
• D. Monitor for changes in heart rate and rhythm.

Correct answer: B

Rationale: Correct Answer: B. Signs of increased intracranial pressure, such as changes in consciousness or pupil reactivity, are critical to monitor in children with bacterial meningitis to prevent complications. Monitoring the client’s skin for rash and lesions (Choice A) is not the priority in bacterial meningitis. While monitoring blood pressure (Choice C) is important, signs of increased intracranial pressure take precedence. Monitoring for changes in heart rate and rhythm (Choice D) is less specific to the condition and may not indicate worsening neurological status.

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