Nursing Elites

1. The client has received 250 ml of 0.9% normal saline through the IV line in the last hour. The client is now tachypneic and has a pulse rate of 120 beats/minute, with a pulse volume of +4. In addition to reporting the assessment findings to the healthcare provider, what action should the nurse implement?

• A. Discontinue the IV and apply pressure at the site.
• B. Decrease the saline to a keep-open rate.
• C. Increase the rate of the current IV solution.
• D. Change the IV fluid to 0.45% normal saline at the same rate.

Correct answer: B

Rationale: In this scenario, the client is showing signs of fluid overload with tachypnea and a high pulse rate. Decreasing the saline to a keep-open rate is appropriate to prevent further fluid volume excess. This action allows for IV access to be maintained while reducing the fluid administered, helping to manage the symptoms of fluid overload.

2. When should the charge nurse intervene based on the observed behavior?

• A. Two staff members are overheard talking about a cure for AIDS outside a client's room.
• B. A hospital transporter is reading a client's history and physical while waiting for an elevator.
• C. A UAP tells a client, 'It's hard to quit drinking but Alcoholics Anonymous helped me.'
• D. Two visitors are discussing a hospitalized client's history of drug abuse in the visitor's lounge.

Correct answer: B

Rationale: The hospital transporter reading a client's history and physical without a legitimate need violates patient confidentiality. This behavior requires immediate intervention to protect the client's privacy and confidentiality rights.

3. The nurse is caring for a client with a spinal cord injury. Which intervention should the nurse implement to prevent autonomic dysreflexia?

• A. Restrict the client's fluid intake.
• B. Keep the client's room warm.
• C. Ensure the client's bladder is emptied regularly.
• D. Limit the client's intake of high-fiber foods.

Correct answer: C

Rationale: To prevent autonomic dysreflexia in clients with spinal cord injuries, it is crucial to ensure the client's bladder is emptied regularly. Bladder distention is a common trigger for autonomic dysreflexia in these clients. Keeping the bladder empty helps prevent the complications associated with autonomic dysreflexia, such as dangerously high blood pressure. Choices A, B, and D are incorrect. Restricting fluid intake can lead to dehydration, keeping the room warm is not directly related to preventing autonomic dysreflexia, and limiting high-fiber foods is not a primary intervention for this condition.

4. A client with a history of hypertension is prescribed hydrochlorothiazide. Which instruction should the nurse include in the client's teaching?

• A. Take this medication in the morning.
• B. Avoid foods high in potassium.
• C. Monitor your blood pressure regularly.
• D. Decrease your intake of high-sodium foods.

Correct answer: C

Rationale: Regular monitoring of blood pressure is crucial for individuals with hypertension to assess the effectiveness of the prescribed medication and to ensure blood pressure is within the target range. This helps in managing hypertension and preventing complications associated with high blood pressure. Choices A, B, and D are incorrect because while taking the medication in the morning may be recommended for some drugs, it is not the key instruction for hydrochlorothiazide. Avoiding foods high in potassium and decreasing high-sodium foods are important dietary considerations for certain conditions, but they are not the immediate focus when starting hydrochlorothiazide.

5. A 46-year-old man with a history of cirrhosis is brought in by his wife because he has been acting strangely. On examination, he is disoriented, ataxic, and has slurred speech. He is also hyperreflexic. His white blood cell count is normal. His hematocrit is 34%. Coagulation times are elevated. His ammonia level is normal. Which of the following statements regarding his management is correct?

• A. He should be treated with a low-protein diet and lactulose
• B. Lorazepam is not the drug of choice to control his behavior
• C. He should not be placed on gentamicin prophylactically to prevent the development of peritonitis
• D. If the patient complains of pain, acetaminophen should be avoided and nonsteroidal anti-inflammatory agents should be used

Correct answer: A

Rationale: This patient presents with symptoms consistent with hepatic encephalopathy. Despite having a normal ammonia level, he should be treated with lactulose and a low-protein diet as recommended for stage 2 hepatic encephalopathy. The normal ammonia level does not exclude the diagnosis, as it lacks sensitivity and specificity. Medications like lorazepam, gentamicin, and NSAIDs should be avoided due to their potential adverse effects in patients with liver disease. Acetaminophen should also be avoided in such patients.

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