Nursing Elites

1. In assessing an adult client with a partial rebreather mask, the nurse notes that the oxygen reservoir bag does not deflate completely during inspiration and the client's respiratory rate is 14 breaths/minute. What action should the nurse implement?

• A. Encourage the client to take deep breaths
• B. Remove the mask to deflate the bag
• C. Increase the liter flow of oxygen
• D. Document the assessment data

Correct answer: D

Rationale: The correct action for the nurse to implement is to document the assessment data. In this scenario, the findings indicate that the partial rebreather mask is functioning correctly as the reservoir bag should not deflate completely during inspiration. Additionally, the client's respiratory rate of 14 breaths/minute falls within the normal range. There is no need to encourage the client to take deep breaths, as the respiratory rate is normal, and doing so may disrupt the client's breathing pattern. Removing the mask to deflate the bag or increasing the liter flow of oxygen are unnecessary actions based on the assessment findings.

2. An adult female client is admitted to the psychiatric unit with a diagnosis of major depressive disorder. The nurse notices the client has more energy and is giving her belongings away. Which intervention is best for the nurse to implement?

• A. Support the client by praising her progress.
• B. Ask the client if she has had any recent thoughts of harming herself.
• C. Reassure the client about the effectiveness of antidepressant drugs.
• D. Advise the client to keep her belongings for discharge.

Correct answer: B

Rationale: The correct intervention is to ask the client if she has had any recent thoughts of harming herself because increased energy and giving away belongings can be signs of suicidal ideation. Choice A is incorrect as it does not address the potential risk of self-harm. Choice C is incorrect because reassurance about medication effectiveness may not be appropriate in this situation. Choice D is incorrect as it dismisses the client's current behavior without addressing the underlying concern of potential self-harm.

3. An adult female client is admitted to the psychiatric unit because of a complex handwashing ritual she performs daily that takes two hours or longer to complete. She worries about staying clean and refuses to sit on any of the chairs in the day area. This client's handwashing is an example of which clinical behavior?

• A. Addiction
• B. Phobia
• C. Compulsion
• D. Obsession

Correct answer: C

Rationale: The client’s handwashing ritual is a compulsion, a repetitive behavior driven by the need to reduce anxiety associated with an obsession. In this case, the client's need to wash her hands excessively stems from an obsession with cleanliness, leading to the compulsive behavior of extensive handwashing. 'Addiction' (Choice A) involves a dependence on a substance or behavior, not related to this scenario. 'Phobia' (Choice B) is an intense fear of a specific object or situation, not applicable here. 'Obsession' (Choice D) refers to persistent and intrusive thoughts, while the handwashing behavior in this case is the compulsive action taken to alleviate the anxiety related to the obsession.

4. The nurse is caring for a client with a history of atrial fibrillation who is receiving warfarin (Coumadin). Which laboratory value should be closely monitored?

• A. Serum potassium level
• B. Prothrombin time (PT)
• C. International Normalized Ratio (INR)
• D. Serum sodium level

Correct answer: C

Rationale: The correct answer is C, International Normalized Ratio (INR). The INR should be closely monitored in a client receiving warfarin (Coumadin) to assess the effectiveness and safety of anticoagulation therapy. Monitoring the INR helps ensure that the client is within the therapeutic range for anticoagulation to prevent complications such as bleeding or clotting. Choices A, B, and D are incorrect. While monitoring electrolyte levels like serum potassium and sodium is important in overall client care, they are not specific to monitoring the effects of warfarin therapy. Prothrombin time (PT) is a component of INR and helps in monitoring warfarin therapy, but INR gives a standardized result that is independent of the laboratory method used, making it the preferred choice for monitoring warfarin therapy.

5. A client with type 2 diabetes is admitted with hyperglycemic hyperosmolar syndrome (HHS). Which intervention should the nurse implement first?

• A. Administer intravenous fluids.
• B. Monitor the client's urine output.
• C. Obtain a blood glucose level.
• D. Administer 50% dextrose IV push.

Correct answer: D

Rationale: The correct answer is to administer 50% dextrose IV push first. In hyperglycemic hyperosmolar syndrome, the main goal is to rapidly reduce blood glucose levels to prevent further complications. Administering dextrose intravenously can help reverse the effects of high blood glucose levels quickly. Administering intravenous fluids, monitoring urine output, and obtaining a blood glucose level are important interventions but are not the first priority in treating HHS. Administering 50% dextrose IV push takes precedence as it directly addresses the elevated blood glucose levels.

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