Nursing Elites

1. Several clients on a telemetry unit are scheduled for discharge in the morning, but a telemetry-monitored bed is needed immediately. The charge nurse should make arrangements to transfer which client to another medical unit?

• A. Learning to self-administer insulin injections after being diagnosed with diabetes mellitus
• B. Ambulatory following coronary artery bypass graft surgery performed six days ago
• C. Wearing a sling immobilizer following permanent pacemaker insertion earlier that day
• D. Experiencing syncopal episodes resulting from the dehydration caused by severe diarrhea

Correct answer: A

Rationale: The correct answer is A because transferring a stable client who is learning self-care, such as self-administering insulin injections after being diagnosed with diabetes mellitus, provides the needed telemetry-monitored bed without compromising the client's care. Choice B should not be transferred as the client is ambulatory following surgery and does not require telemetry monitoring. Choice C should not be transferred as the client is wearing a sling immobilizer following pacemaker insertion, which requires close monitoring. Choice D should not be transferred as the client is experiencing syncopal episodes due to severe dehydration, necessitating telemetry monitoring for immediate intervention.

2. A client diagnosed with a deep vein thrombus (DVT) followed by a diagnosis of pulmonary embolism (PE) is receiving heparin via an infusion pump at a rate of 1400 u/hour. The client tells the nurse, 'I wish this medicine would hurry up and dissolve this clot in my lung so that I can go home'. What response is best for the nurse to provide?

• A. Heparin prevents future clot formation, but your risk of bleeding needs to be monitored closely
• B. You seem to be concerned about the length of time it takes for Heparin to dissolve this clot
• C. Let me contact your surgeon and find out if Heparin IV therapy can be administered to you at home
• D. Why are you so anxious to leave the hospital when you know you are not well enough yet?

Correct answer: A

Rationale: Choice A is the best response because it educates the client about the role of heparin in preventing future clot formation rather than dissolving the existing clot. This helps the client understand the medication's function and the importance of closely monitoring for signs of bleeding, a common side effect of heparin therapy. Choice B acknowledges the client's concern but does not provide accurate information about heparin's mechanism of action. Choice C is premature as it suggests transitioning to home therapy without addressing the client's concerns or explaining heparin's purpose. Choice D does not address the client's statement and instead questions their desire to leave the hospital.

3. The nurse working in an emergency center collects physical evidence 6 hours following a reported sexual assault. After placing the samples in sealed containers, which action is most important for the nurse to implement?

• A. Maintain possession of the evidence collection kit at all times until submitted to law enforcement
• B. Provide discharge instructions for prophylactic antibiotics, pregnancy, and HIV prevention medication
• C. Document the characteristics of the various sites of sample collection
• D. Assist the client with toileting, hygiene, and dressing with clean clothes

Correct answer: A

Rationale: Maintaining possession of the evidence collection kit at all times until submitted to law enforcement is crucial to ensure the integrity of the chain of custody. This step helps prevent tampering or contamination of the evidence, which is vital for the legal process. Providing discharge instructions for medications, documenting sample characteristics, and assisting the client with personal care are important aspects of care but not the immediate priority when handling forensic evidence in a sexual assault case.

4. The nurse is caring for a laboring 22-year-old primigravida following administration of regional anesthesia. In planning care for this client, what nursing intervention has the highest priority?

• A. Raising the side rails and placing the call bell within reach
• B. Teaching the client how to push effectively to decrease the length of the second stage of labor
• C. Timing and recording uterine contractions
• D. Positioning the client for proper distribution of anesthesia

Correct answer: A

Rationale: The highest priority nursing intervention for a laboring client following administration of regional anesthesia is to ensure safety by raising the side rails and placing the call bell within reach. This is crucial to prevent falls and to ensure that the client can call for assistance if needed. Teaching the client how to push effectively (Choice B) is important but not the highest priority at this moment. Timing and recording uterine contractions (Choice C) are essential but not as immediate as ensuring safety post-anesthesia. Positioning the client for proper distribution of anesthesia (Choice D) is important but ensuring immediate safety takes precedence in this situation.

5. What instruction is most important for the nurse to provide a female client who has just been diagnosed with trichomoniasis?

• A. Avoid douching
• B. Treat sexual partner(s) concurrently
• C. Avoid using moist washcloths when bathing
• D. Postpone becoming pregnant until the infection is treated

Correct answer: B

Rationale: The most important instruction for a female client diagnosed with trichomoniasis is to treat sexual partner(s) concurrently. This is crucial to prevent reinfection and the spread of the infection. Choice A, avoiding douching, is generally recommended for vaginal health but is not the most critical instruction in this case. Choice C, avoiding moist washcloths when bathing, is not directly related to the transmission or treatment of trichomoniasis. Choice D, postponing pregnancy until the infection is treated, is important but treating sexual partners concurrently takes precedence to prevent reinfection.

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