Nursing Elites

1. When discussing hair loss with Mrs. Lim, who begins to cry, the best response would be:

• A. Don’t worry. It’s only temporary
• B. Why are you crying? I didn’t get to the bad news yet
• C. Your hair is really pretty
• D. I know this will be difficult for you, but your hair will grow back after the completion of chemotherapy

Correct answer: D

Rationale: When a patient is emotionally affected, it is essential to acknowledge their feelings while providing reassurance and information. Option D demonstrates empathy by acknowledging the difficulty Mrs. Lim is facing and offers hope by reassuring her that her hair will grow back after chemotherapy, which can provide comfort and support during a challenging time.

2. When a client is comatose and has advance directives stating a desire to avoid life-sustaining measures, but the family wants these measures, what action should the nurse take?

• A. Arrange for an ethics committee meeting to address the family's concerns.
• B. Support the family's decision and initiate life-sustaining measures.
• C. Complete an incident report.
• D. Encourage the family to contact an attorney.

Correct answer: A

Rationale: In this scenario, the nurse should prioritize the client's wishes as outlined in the advance directives. By arranging for an ethics committee meeting, the nurse can facilitate discussions between the family and healthcare team to ensure that the client's wishes are respected while addressing the concerns of the family. This approach promotes ethical decision-making and collaborative communication among all involved parties, ultimately aiming to provide the best possible care for the client while considering their autonomy and preferences.

3. A healthcare professional is receiving a telephone prescription from a provider for a client who requires additional medication for pain control. Which of the following entries should the healthcare professional make in the medical record?

• A. Morphine 3 mg Subcutaneous every 4 hr. PRN for pain.
• B. Morphine 3 mg Subcutaneous
• C. Morphine 3.0 mg subcutaneously every 4 hr. PRN for pain.
• D. Morphine 3 mg Subcutaneous q 4 hr. PRN for pain.

Correct answer: D

Rationale: The correct entry for documenting the prescription for morphine is 'Morphine 3 mg Subcutaneous'. This entry accurately specifies the medication, dosage, route of administration, and frequency as prescribed by the provider. Options A, C, and D contain minor errors such as missing units of measurement or incorrect abbreviations, which could lead to misinterpretation or potential medication errors. Therefore, the most appropriate and accurate choice is 'Morphine 3 mg Subcutaneous'.

4. When a family of an accident victim, who has been declared brain-dead, appears open to organ donation, what should the nurse do?

• A. Discourage them from deciding until their grief has eased
• B. Listen to their concerns and answer their questions truthfully
• C. Urge them to immediately sign the consent form
• D. Inform them that the body will not be available for a wake or funeral

Correct answer: B

Rationale: In situations involving potential organ donation, the nurse's role is to provide support, listen to the family's concerns, and answer their questions truthfully. By doing so, the nurse can help facilitate an informed and respectful decision-making process for the grieving family.

5. A client is to receive a transfusion of packed RBCs. Which of the following actions should the nurse take?

• A. Prime IV tubing with 0.9% sodium chloride
• B. Use a 24-gauge IV catheter
• C. Obtain filterless IV tubing
• D. Place blood in the warmer for 1 hr

Correct answer: A

Rationale: Prior to administering a blood transfusion, it is essential to prime the IV tubing with 0.9% sodium chloride to prevent hemolysis of the blood cells. Using a smaller gauge IV catheter (e.g., 20 or 22 gauge) is recommended for blood transfusions to prevent hemolysis. Filterless IV tubing is contraindicated for blood transfusions as it does not have a filter to trap potential blood clots or debris. Warming blood is unnecessary and could lead to the development of bacteria in the blood product. Therefore, the correct action for the nurse to take is to prime the IV tubing with 0.9% sodium chloride.

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