Nursing Elites

1. The nurse is providing care for a client with syndrome of inappropriate antidiuretic hormone (SIADH). Which assessment finding requires immediate intervention?

• A. Serum sodium of 140 mEq/L.
• B. Serum osmolality of 280 mOsm/kg.
• C. Weight gain of 2 pounds in 24 hours.
• D. Serum sodium of 130 mEq/L.

Correct answer: D

Rationale: The corrected answer is D. A serum sodium level of 130 mEq/L indicates hyponatremia, which requires immediate intervention in a client with SIADH. Hyponatremia can lead to serious complications such as seizures, coma, and cerebral edema. Choices A, B, and C are not the most critical findings in a client with SIADH. While a serum sodium of 140 mEq/L is within the normal range, a decrease to 130 mEq/L is concerning and requires prompt action to prevent complications.

2. The nurse is conducting a process evaluation of a prevention education program for older adults who are at risk for substance abuse. Which data source provides the information the nurse needs to conduct this process evaluation?

• A. client's score on an alcohol screening instrument
• B. results of a urine drug and alcohol screen
• C. most recent community census data
• D. documentation of client education in the nursing record

Correct answer: D

Rationale: The correct answer is D. Documentation of client education in the nursing record provides information on the implementation and progress of the educational program, which is crucial for evaluating its process. Choices A and B focus on individual client assessment rather than program evaluation. Choice C, community census data, is not directly related to evaluating the process of the prevention education program for older adults at risk for substance abuse.

3. A male client who had abdominal surgery has a nasogastric tube for suction, oxygen via nasal cannula, and complains of dry mouth. Which action should the nurse implement?

• A. Apply a petroleum-based lubricant to the lips.
• B. Give sips of water.
• C. Provide ice chips.
• D. Apply a water-soluble lubricant to the lips, oral mucosa, and nares.

Correct answer: D

Rationale: In this scenario, the correct action is to apply a water-soluble lubricant to the lips, oral mucosa, and nares. This helps in keeping the mucous membranes moist, which is essential for a client with a dry mouth due to the nasogastric tube and oxygen therapy. Choice A, applying a petroleum-based lubricant to the lips, is not suitable as it may not be safe for internal use. Choice B, giving sips of water, is contraindicated as the client has a nasogastric tube in place for suction. Choice C, providing ice chips, is also not recommended as the client needs proper lubrication to address dryness, not cold stimulation.

4. A first-grade boy is sent to the school nurse after he fainted while playing tag during recess. When he arrives in the clinic he is alert and oriented and his vital signs include temperature of 97.8°F, pulse 96 bpm, respirations 15 breaths/minute, and blood pressure 80/56 mmHg. Which intervention is most important for the nurse to implement?

• A. request transport of the child to his pediatrician's office
• B. call the child's parents and send him home for the day
• C. compare the child's body mass index to normal values
• D. measure the child's pulse and blood pressure every 15 minutes

Correct answer: D

Rationale: In this scenario, the most important intervention for the nurse to implement is to measure the child's pulse and blood pressure every 15 minutes. The child experienced a syncopal episode (fainting) which could be due to various reasons, including dehydration or cardiac issues. Monitoring vital signs frequently will help detect any changes that may indicate underlying health issues. Requesting transport to the pediatrician's office or sending the child home without continuous monitoring may not provide immediate assessment and intervention. Comparing the child's body mass index to normal values is not relevant in addressing the immediate concern of monitoring vital signs after a syncopal episode.

5. The healthcare professional is preparing to administer a blood transfusion to a client with anemia. Which action is most important to prevent a transfusion reaction?

• A. Check the client's vital signs before starting the transfusion.
• B. Use a blood filter when administering the transfusion.
• C. Verify the blood type and Rh factor with another healthcare professional.
• D. Administer antihistamines before starting the transfusion.

Correct answer: C

Rationale: Verifying the blood type and Rh factor with another healthcare professional is the most crucial action to prevent a transfusion reaction. Ensuring compatibility between the donor blood and the recipient is essential in preventing adverse reactions such as hemolytic transfusion reactions. Checking vital signs is important for monitoring the client during the transfusion process but does not directly prevent a transfusion reaction. Using a blood filter can help remove clots and debris but does not address the risk of a reaction due to blood type incompatibility. Administering antihistamines before the transfusion is not a standard practice to prevent transfusion reactions related to blood type incompatibility.

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