Nursing Elites

1. The nurse is caring for a client following an appendectomy. The client reports nausea and complains of surgical site pain at a 6 on a 0 to 10 scale. The client's employer is present in the room and states he is paying for the insurance and wants to know what pain medication has been prescribed by the physician. Which of the following is the appropriate nurse response?

• A. Answer any questions the employer may have as he pays for the insurance.
• B. Tell the employer his question is inappropriate and that the information is none of his business.
• C. Explain to the employer that you cannot release private information and ask the employer to step out while you conduct your assessment of the client.
• D. Ask the employer to leave and wait until the client returns home to visit.

Correct answer: C

Rationale: The appropriate nurse response is to explain to the employer that private information cannot be released and ask the employer to step out while conducting the assessment. This approach respects the client's privacy while still acknowledging the employer. The employer's payment for insurance does not grant rights to confidential information. Sharing information without permission violates the client's right to privacy under HIPAA. Option A is incorrect as it compromises the client's confidentiality by sharing private medical information. Option B is inappropriate and unprofessional as it does not address the situation respectfully. Option D is incorrect as it does not prioritize the client's immediate needs and assumes the client's consent without proper communication.

2. When preparing a client for platelet pheresis in the blood bank, which information is most significant to obtain during the history assessment?

• A. Allergies to shellfish
• B. Date of last platelet donation
• C. Time of last oral intake
• D. Blood type

Correct answer: B

Rationale: The most significant information to gather when a client is scheduled for platelet pheresis is the date of their last platelet donation. Platelet donors can typically have their platelets apheresed as frequently as every 14 days. Knowing the date of the last donation helps ensure the client is eligible for the procedure without risking any adverse effects from frequent donations. Allergies to shellfish may be important for other procedures where anticoagulants containing heparin are used, but it is not directly related to platelet pheresis. The time of the last oral intake is more crucial for procedures requiring sedation or anesthesia. Blood type is significant for blood transfusions but is not the primary concern for platelet pheresis.

3. The client is wheezing and struggling to breathe. Which of the inhaled medications is indicated at this time?

• A. Fluticasone (Flovent)
• B. Salmeterol (Serevent)
• C. Theophylline (Theodur)
• D. Albuterol (Atrovent)

Correct answer: D

Rationale: The correct answer is Albuterol (Atrovent) because it is a rapid-acting bronchodilator, essential for a client experiencing wheezing and difficulty breathing. Albuterol acts quickly, dilating the airways and providing immediate relief in cases of respiratory distress. Fluticasone (Flovent) and Salmeterol (Serevent) are maintenance medications for long-term asthma control, not suitable for acute situations described. Theophylline (Theodur) is a bronchodilator but with a slower onset compared to Albuterol, making it less appropriate for a client in immediate distress.

4. The manic client has just interrupted the group session with the counselor for the 4th time, explaining that she already knows this information on 'dealing with others when you are down' and constantly gets up and goes to the front. What should the nurse do at this time?

• A. Engage the client to walk with you to make another pot of coffee
• B. Ask the client to reflect on their behavior to determine if it is appropriate
• C. Ask the group to tell the client how they feel when she interrupts
• D. Instruct the client to perform jumping jacks and count aloud to get rid of some energy

Correct answer: A

Rationale: In this situation, it is important to redirect the client's energy and focus. Engaging the client in a purposeful activity like making another pot of coffee can help distract them from disruptive behavior and provide an outlet for their excess energy. This choice also helps in maintaining a therapeutic environment by involving the client in a constructive task. Asking the client to reflect on their behavior (Choice B) might not be effective during a manic episode as the client may not be in a state to critically analyze their actions. Asking the group to tell the client how they feel (Choice C) can escalate the situation and may not be appropriate in this context. Instructing the client to perform jumping jacks and count aloud (Choice D) may not address the underlying issue of disruptive behavior and may not be suitable for the current situation.

5. Is head lag expected to be resolved by 4 months of age? Continuing head lag at 6 months of age may indicate?

• A. Dizziness and orthostatic hypotension.
• B. Nausea, vomiting, diarrhea, or constipation, and stomach cramps.
• C. Drowsiness, lethargy, and fatigue.
• D. Neuropathy and tingling in the extremities.

Correct answer: B

Rationale: Head lag is a developmental milestone that should be resolved by 4 months of age. Continuing head lag at 6 months of age may indicate potential developmental delays or muscle weakness. The correct answer, 'Nausea, vomiting, diarrhea, or constipation, and stomach cramps,' reflects symptoms that could be associated with developmental delays or underlying health conditions. Dizziness and orthostatic hypotension (Choice A) are unlikely to be directly related to head lag. Choices C and D present symptoms that are unrelated to the issue of continued head lag at 6 months of age.

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