Nursing Elites

1. On admission to the Emergency Department, a female client who was diagnosed with bipolar disorder 3 years ago reports that this morning she took a handful of medications and left a suicide note for her family. Which information is most important for the nurse to obtain?

• A. Which family member has the client's suicide note?
• B. When the client last took medications for bipolar disorder?
• C. What medications the client used for the suicide attempt?
• D. Whether the client has ever attempted suicide in the past?

Correct answer: C

Rationale: Identifying the specific medications taken during a suicide attempt is crucial for determining the appropriate treatment and assessing the potential toxicity or interactions. This information helps healthcare providers initiate the necessary interventions promptly. Option A is not as critical as knowing the medications used. Option B focuses on the timing of the last medication intake rather than the specific drugs taken for the overdose. Option D, while relevant, does not provide immediate actionable information compared to identifying the substances involved in the suicide attempt.

2. An older client is having photocoagulation for macular degeneration. What intervention should the nurse implement during post-procedure care in the outpatient surgical unit?

• A. Apply bilateral eye patches while sleeping
• B. Use a whiteboard to communicate with the client
• C. Arrange food on the plate in a clockwise order
• D. Verbally identify oneself when entering the room

Correct answer: A

Rationale: The correct intervention is to apply bilateral eye patches while sleeping. This measure helps protect the eyes and support healing following photocoagulation for macular degeneration. Choice B is incorrect as using a whiteboard is not directly related to post-procedure care for this intervention. Choice C is incorrect as arranging food on the plate in a clockwise order is not relevant to the post-procedure care of photocoagulation. Choice D is incorrect as verbally identifying oneself when entering the room is important for communication but not specific to the post-procedure care in this scenario.

3. Two hours after delivering a 9-pound infant, a client saturates a perineal pad every 15 minutes. Although an IV containing Pitocin is infusing, her uterus remains boggy, even with massage. The healthcare provider prescribes methylergometrine maleate (Methergine) 0.2 mg IM STAT. Which complication should the nurse be alert to this client developing?

• A. Decreased respiratory rate
• B. Increased temperature
• C. Tachycardia
• D. Hypertension

Correct answer: D

Rationale: The correct answer is D: Hypertension. Methylergometrine maleate (Methergine) is a medication used to prevent or control postpartum hemorrhage by causing uterine contractions. One of the potential side effects is hypertension. Therefore, the nurse should closely monitor the client's blood pressure after administering Methergine. Choices A, B, and C are incorrect because Methergine is not known to cause decreased respiratory rate, increased temperature, or tachycardia.

4. An adult male was diagnosed with stage IV lung cancer three weeks ago. His wife approaches the nurse and asks how she will know that her husband's death is imminent because their two adult children want to be there when he dies. What is the best response by the nurse?

• A. Explain that the client will start to lose consciousness and his body systems will slow down
• B. Reassure the spouse that the healthcare provider will let her know when to call the children
• C. Offer to discuss the client’s health status with each of the adult children
• D. Gather information on how long it will take for the children to arrive

Correct answer: A

Rationale: The best response for the nurse is to explain that the client will start to lose consciousness and his body systems will slow down. Providing information on the signs of impending death helps the family prepare emotionally and allows them to be present at the appropriate time. Choice B is incorrect because it does not empower the family with the knowledge they seek. Choice C is incorrect as discussing the client’s health status individually with the adult children may not address the wife's immediate concern. Choice D is incorrect as the priority should be on preparing the family for the signs of imminent death rather than focusing on logistical details.

5. When conducting diet teaching for a client who is on a postoperative full liquid diet, which foods should the nurse encourage the client to eat?

• A. Vanilla frozen yogurt
• B. Vegetable juice
• C. Clear beef broth
• D. Canned fruit cocktail

Correct answer: A

Rationale: The correct answer should be provided as choice E: Vanilla frozen yogurt. For a postoperative full liquid diet, the nurse should encourage the client to eat foods that are fully liquid and easy to digest. Vanilla frozen yogurt is a suitable choice as it provides calories and nutrients while being in a liquid form. Creamy peanut butter, vegetable juice, and canned fruit cocktail are not appropriate for a full liquid diet as they are not fully liquid and may not be easy to digest. Creamy peanut butter is solid, vegetable juice is not fully liquid, and canned fruit cocktail contains solid pieces.

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