Nursing Elites

1. When giving a report about a client who had a gastrectomy from the intensive care unit to the post-surgical unit nurse, what is the most effective way to assure essential information is reported?

• A. Give the report face-to-face with both nurses in a quiet room.
• B. Audiotape the report for future reference and documentation.
• C. Use a printed checklist with information individualized for the client.
• D. Document essential transfer information in the client's electronic health record.

Correct answer: C

Rationale: Using a printed checklist with individualized information is the most effective way to ensure that all key details about the client who had a gastrectomy are covered during the report. This method helps in structuring the information systematically, reducing the risk of missing important details. Face-to-face communication in a quiet room (Choice A) is important for effective communication but may not guarantee the coverage of all essential information. Audiotaping the report (Choice B) may not be practical for immediate reference or interaction. Documenting in the electronic health record (Choice D) is essential but may not facilitate a comprehensive real-time exchange of information between the nurses.

2. A client in the postanesthesia care unit has an as-needed prescription for ondansetron (Zofran). Which of the following occurrences would prompt the nurse to administer this medication to the client?

• A. Paralytic ileus
• B. Incisional pain
• C. Urine retention
• D. Nausea and vomiting

Correct answer: D

Rationale: The correct answer is D: Nausea and vomiting. Ondansetron is an antiemetic used to manage postoperative nausea and vomiting, as well as nausea and vomiting related to chemotherapy. It is not indicated for treating paralytic ileus, incisional pain, or urine retention. Paralytic ileus is a condition of the gastrointestinal tract characterized by the paralysis of intestinal muscles, which would not be treated with ondansetron. Incisional pain is typically managed with analgesics, not antiemetics. Urine retention is a urinary issue that does not involve nausea and vomiting, making ondansetron an inappropriate choice for this condition.

3. The client with chronic renal failure is being educated on dietary restrictions. Which of the following foods should the client avoid?

• A. Bananas.
• B. Oranges.
• C. Rice.
• D. Apples.

Correct answer: A

Rationale: The correct answer is A: Bananas. Bananas are high in potassium, and clients with chronic renal failure are often advised to follow a low-potassium diet to prevent hyperkalemia. Oranges and apples are also high in potassium and should be avoided by clients with renal issues. Rice, on the other hand, is low in potassium and is generally considered safe for individuals with chronic renal failure to consume in moderation.

4. Which of the following assessments is the most important for a patient receiving IV potassium?

• A. Respiratory rate
• B. Heart rate
• C. Blood pressure
• D. Oxygen saturation

Correct answer: C

Rationale: The most important assessment for a patient receiving IV potassium is monitoring blood pressure. IV potassium can cause significant changes in cardiac function, leading to adverse effects such as arrhythmias and cardiac arrest. While respiratory rate, heart rate, and oxygen saturation are important parameters to monitor in clinical practice, blood pressure takes precedence in patients receiving IV potassium due to its direct impact on cardiovascular function. Changes in blood pressure can be an early indicator of potassium-induced cardiac complications, making it crucial to monitor closely during administration.

5. An older adult client with a long history of chronic obstructive pulmonary disease (COPD) is admitted with progressive shortness of breath and a persistent cough. The client is anxious and complaining of a dry mouth. Which intervention should the nurse implement?

• A. Assist the client to an upright position
• B. Administer a prescribed sedative
• C. Apply a high-flow Venturi mask
• D. Encourage the client to drink water

Correct answer: A

Rationale: Assisting the client to an upright position is the most appropriate intervention in this scenario. An upright position helps optimize lung expansion and aids in improving ventilation, which can alleviate shortness of breath. This position also assists in reducing anxiety by providing a sense of control and comfort. Administering a sedative (Choice B) may further depress the respiratory drive in a client with COPD and should be avoided unless absolutely necessary. Applying a high-flow Venturi mask (Choice C) may be indicated later based on oxygenation needs, but the immediate focus should be on positioning. Encouraging the client to drink water (Choice D) may not directly address the respiratory distress and anxiety experienced by the client.

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