Nursing Elites

1. The nurse is providing post-operative care to the craniotomy client. Diabetes insipidus is suspected when the client's urine output suddenly increases significantly. Which action takes highest priority?

• A. Continue to monitor urine output
• B. Check a pulse
• C. Check a blood pressure
• D. Check level of consciousness (LOC)

Correct answer: C

Rationale: The correct answer is to check a blood pressure. Diabetes insipidus can lead to dehydration and potential hypovolemic shock due to excessive urine output. Monitoring blood pressure is crucial to assess the client's circulatory status and detect signs of shock early. Checking the blood pressure will provide essential information on perfusion, which is vital in this situation. Continuing to monitor urine output, checking a pulse, or assessing the level of consciousness are important but not as high a priority as evaluating the blood pressure in a potentially critical situation like suspected diabetes insipidus.

2. To determine the standards of care for the institution, the nurse should consult?

• A. Organizational Chart
• B. Personnel policies
• C. Policies and procedure manual
• D. Job descriptions

Correct answer: C

Rationale: The correct answer is the 'Policies and procedure manual.' This manual outlines the policies and procedures that govern patient care within the institution, including the standards of care that healthcare providers are expected to follow. Consulting the policies and procedure manual ensures that the nurse is adhering to the established guidelines and protocols. Choices A, B, and D are incorrect because although they are important documents within an institution, they do not specifically define the standards of care for patient management. The organizational chart illustrates the hierarchy of the institution, personnel policies outline rules related to employees, and job descriptions detail specific roles and responsibilities, none of which directly define patient care standards.

3. During a petit mal seizure in the clinic, what should be the highest priority?

• A. Provide a safe environment free of obstructions in the immediate area
• B. Call a code
• C. Contact the patient's physician
• D. Prevent excessive movement of the extremities

Correct answer: A

Rationale: During a petit mal seizure, the highest priority is to provide a safe environment free of obstructions in the immediate area. This action aims to prevent injuries to the patient during the seizure. While calling a code or contacting the patient's physician may be necessary at some point, immediate safety measures take precedence. Preventing excessive movement of the extremities is relevant but ensuring a safe environment is crucial to avoid harm during the seizure.

4. A client is admitted to the floor with vomiting and diarrhea for three days. She is receiving IV fluids at 200cc/hr via pump. A priority action for the nurse would be:

• A. Obtaining Intake and Output.
• B. Frequent lung assessments.
• C. Vital signs every shift.
• D. Monitoring the IV site for infiltration.

Correct answer: D

Rationale: In this scenario, the correct priority action for the nurse would be monitoring the IV site for infiltration. The client is receiving IV fluids at a rapid rate, making it crucial to ensure that the IV site is intact and not causing any complications like infiltration, which can lead to tissue damage. While frequent lung assessments are important for detecting signs of fluid overload, in this case, ensuring the IV site's integrity takes precedence. Obtaining Intake and Output is relevant but not the priority over monitoring the IV site. Vital signs are essential, but given the situation, the immediate concern is the IV site's condition to prevent complications.

5. When teaching a client about anti-retroviral therapy for human immunodeficiency virus (HIV), the PN should emphasize:

• A. When started, therapy must not be interrupted to prevent viral resistance.
• B. When started, therapy must not be interrupted to prevent opportunistic infection.
• C. Therapy should not be interrupted for one day each month to prevent toxicity.
• D. Therapy should not be interrupted for one week every three months to prevent toxicity.

Correct answer: A

Rationale: When teaching a client about anti-retroviral therapy for HIV, it is crucial to emphasize that therapy must not be interrupted to prevent viral resistance. HIV mutates rapidly, and any interruption can lead to the emergence of resistant strains, compromising treatment effectiveness. Choice B is incorrect because keeping the virus in check with anti-retrovirals helps the client's immune system fight off opportunistic infections. Choices C and D are incorrect because therapy should not be interrupted for any reason. If toxicity occurs, the healthcare provider may adjust the treatment regimen by prescribing alternative anti-retroviral drugs.

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