Nursing Elites

1. When should the charge nurse intervene based on the observed behavior?

• A. Two staff members are overheard talking about a cure for AIDS outside a client's room.
• B. A hospital transporter is reading a client's history and physical while waiting for an elevator.
• C. A UAP tells a client, 'It's hard to quit drinking but Alcoholics Anonymous helped me.'
• D. Two visitors are discussing a hospitalized client's history of drug abuse in the visitor's lounge.

Correct answer: B

Rationale: The hospital transporter reading a client's history and physical without a legitimate need violates patient confidentiality. This behavior requires immediate intervention to protect the client's privacy and confidentiality rights.

2. Which regimen is most effective for treating H. pylori infection?

• A. Metronidazole, bismuth subsalicylate, amoxicillin for 14 days
• B. Clarithromycin and omeprazole for 14 days
• C. Metronidazole, lansoprazole, and clarithromycin for 14 days
• D. Metronidazole, clarithromycin, and omeprazole for 7 days

Correct answer: C

Rationale: Regimen C, which consists of metronidazole, lansoprazole, and clarithromycin for 14 days, is recommended by the FDA as an effective treatment for H. pylori infection. This regimen has been shown to have a high eradication rate and is a standard recommendation in clinical practice guidelines for the management of H. pylori-related conditions.

3. When evaluating a client's understanding of wearing a Holter monitor, which statement made by the client would indicate to the nurse that the client understands the procedure?

• A. I must record any symptoms occurring with my activity.
• B. I am not looking forward to staying in bed for 24 hours.
• C. I really am dreading the frequent blood drawing.
• D. I know that I shouldn't get close to my microwave oven.

Correct answer: A

Rationale: The correct answer is A. Recording symptoms that occur with activity is crucial when wearing a Holter monitor. This information helps in correlating symptoms with cardiac events, aiding in the diagnosis and treatment of the client's condition. The client's understanding of this aspect demonstrates comprehension of the procedure and its purpose.

4. The client is receiving intravenous (IV) morphine for pain control. Which assessment finding requires the most immediate intervention?

• A. Drowsiness.
• B. Itching.
• C. Nausea.
• D. Respiratory rate of 8 breaths per minute.

Correct answer: D

Rationale: A respiratory rate of 8 breaths per minute indicates severe respiratory depression, a life-threatening side effect of opioid therapy. Immediate intervention is crucial to prevent respiratory failure. Monitoring and managing respiratory status are critical in clients receiving opioids to prevent adverse events. Drowsiness, itching, and nausea are common side effects of morphine but are not as immediately life-threatening as severe respiratory depression.

5. A 34-year-old woman presents with intermittent abdominal pain, bloating, and diarrhea. She notes that her symptoms improve with fasting. She has a history of iron deficiency anemia. What is the most likely diagnosis?

• A. Irritable bowel syndrome
• B. Celiac disease
• C. Lactose intolerance
• D. Crohn's disease

Correct answer: B

Rationale: The patient's symptoms of intermittent abdominal pain, bloating, and diarrhea that improve with fasting, along with a history of iron deficiency anemia, are highly suggestive of celiac disease. In celiac disease, gluten ingestion leads to mucosal damage in the small intestine, causing malabsorption of nutrients like iron, leading to anemia. The improvement of symptoms with fasting can be explained by the temporary avoidance of gluten-containing foods. Irritable bowel syndrome typically does not improve with fasting. Lactose intolerance usually presents with symptoms after dairy consumption, not with fasting. Crohn's disease typically presents with more chronic symptoms and is not commonly associated with improvement on fasting.

Similar Questions