Nursing Elites

1. The nurse asks a client who is about to have a cardiac catheterization about any allergies. The client states, 'I always get a rash when I eat shellfish.' Which of the following is the priority nursing action?

• A. Attach a wristband indicating the client's allergy
• B. Ask the client if any other foods cause such a reaction
• C. Notify the dietary department of the client's allergy
• D. Notify the provider of the client's allergy

Correct answer: D

Rationale: Notifying the provider of the client's shellfish allergy is crucial to prevent a potential reaction from the contrast dye. While attaching a wristband indicating the allergy may be necessary, the priority is to inform the provider. Asking the client about other foods causing a similar reaction or notifying the dietary department, although important, are not the priority in this situation.

2. After signing an informed consent form, a client states, 'I have changed my mind and do not want to have the procedure.' Which of the following actions should the nurse take?

• A. Suggest that family members discuss the importance of the surgery with the client
• B. Notify the surgeon that the client wishes to withdraw informed consent for the procedure
• C. Document the risks of refusing the procedure in the client's medical record
• D. Discuss the benefits of the procedure with the client

Correct answer: B

Rationale: The correct action for the nurse to take in this situation is to notify the surgeon that the client wishes to withdraw informed consent for the procedure. This ensures that the client's right to refuse treatment is respected. Choice A is incorrect because involving family members in this decision could violate the client's autonomy. Choice C is incorrect as it does not address the immediate need to respect the client's decision. Choice D is also incorrect as the client has clearly stated their refusal of the procedure.

3. The patient experienced a surgical procedure, and Betadine was utilized as the surgical prep. Two days postoperatively, the nurse's assessment indicates that the incision is red and has a small amount of purulent drainage. The patient reports tenderness at the incision site. The patient's temperature is 100.5°F, and the WBC is 10,500/mm³. Which action should the nurse take first?

• A. Reevaluate the temperature and white blood cell count in 4 hours.
• B. Check which solution was used for skin preparation in surgery.
• C. Plan to change the surgical dressing during the shift.
• D. Utilize SBAR to notify the primary health care provider.

Correct answer: D

Rationale: The patient is showing signs of a possible surgical site infection, including redness, purulent drainage, tenderness, elevated temperature, and increased white blood cell count. These symptoms suggest the need for immediate action to address a potential complication. Utilizing SBAR to notify the primary health care provider is crucial as it allows for effective communication of the patient's condition and the need for further assessment and intervention. Reevaluating the temperature and white blood cell count later, checking the solution used for skin preparation, or planning to change the dressing do not address the urgent need for intervention and communication with the healthcare provider.

4. Which of the following is a primary focus of tertiary prevention in mental health?

• A. Identifying early signs of mental illness
• B. Preventing the occurrence of mental health problems
• C. Rehabilitation and prevention of further deterioration
• D. Providing a safe environment to prevent harm

Correct answer: C

Rationale: The correct answer is C: Rehabilitation and prevention of further deterioration. Tertiary prevention in mental health aims to provide interventions and support to individuals who already have a mental illness to prevent further deterioration and promote recovery. Choice A, identifying early signs of mental illness, is more aligned with primary prevention which focuses on preventing the onset of mental health problems. Choice B, preventing the occurrence of mental health problems, pertains to secondary prevention which involves early detection and intervention to prevent the progression of mental health issues. Choice D, providing a safe environment to prevent harm, is important but it is not the primary focus of tertiary prevention which is more centered on rehabilitation and improving the quality of life for individuals with existing mental health conditions.

5. What are the clinical manifestations of left-sided heart failure, and how do they differ from right-sided heart failure?

• A. Jugular venous distention and hepatojugular reflex
• B. Hepatomegaly, ascites, and peripheral edema
• C. Dyspnea, cough, and orthopnea
• D. Pulmonary congestion and fatigue

Correct answer: A

Rationale: The correct answer is A. Clinical manifestations of left-sided heart failure include pulmonary symptoms such as dyspnea, cough, and orthopnea. However, left-sided heart failure can also manifest as jugular venous distention and hepatojugular reflex due to the backflow of blood into the pulmonary circulation. Right-sided heart failure is characterized by systemic symptoms like hepatomegaly, ascites, and peripheral edema. Choice B is incorrect as it presents manifestations of right-sided heart failure. Choice C includes symptoms of left-sided heart failure. Choice D describes pulmonary congestion, which is more specific to left-sided heart failure, but it does not encompass the full range of clinical manifestations for left-sided heart failure.

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