Nursing Elites

1. During a report from an ER nurse about a client, the nurse identifies a statement that requires additional follow-up. Which of the following statements needs further clarification?

• A. "The client said they have been taking aspirin, but I'm not sure for how long or how much."?
• B. "The client frequently takes antacids, but they have not taken any in the last three days."?
• C. "The client stopped taking ibuprofen after developing gastric ulcers."?
• D. "The client takes Antabuse and has stopped using mouthwash."?

Correct answer: A

Rationale: The correct answer requires further follow-up as the nurse needs to know the duration and dosage of aspirin since it can impact the patient's bleeding risk. Choice B does not require immediate follow-up as not taking antacids for three days is not critical. Choice C indicates a necessary decision made by the client to stop ibuprofen after developing gastric ulcers, hence no immediate follow-up is needed. Choice D provides important information, but the priority is to address the lack of specificity regarding the client's aspirin use, which is crucial for assessing bleeding risk and potential interactions.

2. What is the intent of the Patient Self Determination Act (PSDA) of 1990?

• A. Enhance personal control over healthcare decisions.
• B. Encourage medical treatment decision making prior to need.
• C. Establish a federal standard for living wills and durable powers of attorney.
• D. Emphasize client education.

Correct answer: B

Rationale: The correct answer is B: The purpose of the PSDA is to encourage medical treatment decision-making before it becomes necessary. This legislation aims to empower individuals to make their own healthcare choices in advance. Choice A is incorrect because while enhancing personal control over healthcare decisions is important, the primary goal of the PSDA is to facilitate medical decision-making before the need arises. Choice C is incorrect as the PSDA does not establish a federal standard for living wills and durable powers of attorney; instead, it encourages individuals to create their own advance directives according to state-specific regulations. Choice D is incorrect because while client education is valuable, the main focus of the PSDA is on empowering individuals to plan for their future healthcare needs.

3. The LPN is admitting a client to the unit, and the client has rapidly blinking eyes, a stuck-out tongue, and a distorted posture. Which of these medications is the client most likely taking?

• A. Clozapine
• B. Fluoxetine
• C. Ondansetron
• D. Haloperidol

Correct answer: D

Rationale: The correct answer is Haloperidol. Haloperidol is a first-generation antipsychotic that blocks dopamine receptors and is most likely to cause extrapyramidal symptoms (EPS), such as tardive dyskinesia. Symptoms of tardive dyskinesia include rapid blinking, mouth movements, sticking out the tongue, rapid body movements, and a distorted posture. Haloperidol is associated with a higher risk of EPS compared to other antipsychotic medications like Clozapine. Clozapine is known for having a lower risk of causing EPS. Fluoxetine is a selective serotonin reuptake inhibitor used for depression and anxiety, not typically associated with these movement disorder symptoms. Ondansetron is an antiemetic used to prevent nausea and vomiting, not linked to these extrapyramidal symptoms.

4. The LPN is about to give 100 mg Lopressor (metoprolol) to a client. Before administering the drug, they take the patient's vitals, which are as follows: Pulse: 58 Blood Pressure: 90/62 Respirations: 18/minute What action should the LPN take?

• A. Give the client half the prescribed dose and report the findings to the RN on duty.
• B. Give the client double the dose and report the findings to the RN on duty.
• C. Administer the drug and report the findings to the RN on duty.
• D. Hold the drug and report the findings to the RN on duty.

Correct answer: D

Rationale: Lopressor is given to treat hypertension, and a pulse of 58 and a blood pressure of 90/62 are considered low. To prevent the client from bottoming out, the drug should be held, and the findings reported to the RN, who should consult with the attending physician. LPNs should never adjust client dosing, as that is outside of their scope of practice. It is crucial to follow facility guidelines, which often recommend holding blood pressure medication at 60 bpm and a systolic pressure of 90 or less. By holding the drug and notifying the RN, the LPN ensures the client's safety and allows for appropriate assessment and decision-making by the healthcare team. Giving half the dose or double the dose without proper authorization can lead to serious complications and is considered unsafe practice.

5. When reviewing a client's medical notes to confirm pregnancy, a nurse should look for which finding to determine that pregnancy is confirmed?

• A. Amenorrhea
• B. Thinning of the cervix
• C. Palpable fetal movement
• D. Positive result on a home urine test for pregnancy

Correct answer: C

Rationale: To confirm pregnancy, the presence of palpable fetal movement is a positive indicator. Palpable fetal movement is a certain sign of pregnancy, known as a fetal movement felt by the examiner. Amenorrhea is a presumptive sign of pregnancy as it is reported by the woman but is not confirmatory. Thinning of the cervix (Hegar sign) is a probable sign of pregnancy, which is not confirmatory. A positive result on a home urine test for pregnancy is also a probable indicator. However, a positive pregnancy test result can sometimes yield false-positive results due to various factors like medication, recent pregnancy, or errors in reading.

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