Nursing Elites

1. The healthcare professional is using the Glasgow Coma Scale to perform a neurologic assessment. A comatose client winces and pulls away from a painful stimulus. What action should the healthcare professional take next?

• A. Document that the client responds to a painful stimulus.
• B. Observe the client's response to verbal stimulation.
• C. Place the client on seizure precautions for 24 hours.
• D. Report decorticate posturing to the healthcare provider.

Correct answer: A

Rationale: The client's response to a painful stimulus indicates a purposeful reaction, which should be accurately documented as per the assessment findings. This documentation is essential for ongoing monitoring and communication of the client's condition to the healthcare team.

2. A client with chronic renal failure is receiving epoetin alfa (Epogen). Which laboratory test should the nurse monitor to evaluate the effectiveness of this medication?

• A. White blood cell count.
• B. Hemoglobin and hematocrit.
• C. Platelet count.
• D. Blood urea nitrogen (BUN) and creatinine.

Correct answer: B

Rationale: The correct answer is B: Hemoglobin and hematocrit. These are the primary laboratory tests to monitor the effectiveness of epoetin alfa (Epogen) in treating anemia. White blood cell count (A), platelet count (C), and blood urea nitrogen (BUN) and creatinine (D) are not directly related to the effects of this medication. Epoetin alfa stimulates the production of red blood cells, so monitoring hemoglobin and hematocrit levels helps assess the response to the treatment.

3. During the digital removal of a fecal impaction, the nurse should stop the procedure and take corrective action if which client reaction is noted?

• A. Temperature increases from 98.8° to 99.0° F.
• B. Pulse rate decreases from 78 to 52 beats/min.
• C. Respiratory rate increases from 16 to 24 breaths/min.
• D. Blood pressure increases from 110/84 to 118/88 mmHg.

Correct answer: B

Rationale: During digital removal of a fecal impaction, a vagal response can occur due to stimulation of the anal sphincter. If the client experiences bradycardia (pulse rate decreases), the nurse should stop the procedure immediately and take corrective action to prevent any complications. Choices A, C, and D are incorrect because they do not indicate a vagal response, which is the expected adverse reaction during this procedure.

4. The client is being taught about the use of syringes and needles for home administration of medications. Which action by the client indicates an understanding of standard precautions?

• A. Remove needle before discarding used syringes
• B. Wear gloves to dispose of the needle and syringe
• C. Don a face mask before administering the medication
• D. Wash hands before handling the needle and syringe

Correct answer: D

Rationale: Washing hands before handling needles and syringes is a crucial aspect of standard precautions to prevent infections. This practice helps reduce the risk of transferring microorganisms from the hands to the syringes and needles, thus promoting safety during medication administration.

5. An older client who had abdominal surgery 3 days earlier was given a barbiturate for sleep and is now requesting to go to the bathroom. Which action should the nurse implement?

• A. Assist the client to walk to the bathroom and do not leave the client alone.
• B. Request that the UAP assist the client onto a bedpan.
• C. Ask if the client needs to have a bowel movement or void.
• D. Assess the client's bladder to determine if the client needs to urinate.

Correct answer: A

Rationale: Barbiturates cause central nervous system (CNS) depression, increasing the risk of falls. It is crucial for the nurse to assist the client to the bathroom to prevent potential injuries. Leaving the client alone may lead to accidents due to the effects of the medication. Monitoring and supporting the client during this activity is essential for ensuring safety and preventing falls.

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