Nursing Elites

1. What does the nurse's signature on the client’s surgical consent form signify?

• A. The client voluntarily grants permission for the procedure to be done
• B. The client is competent to sign the consent without impairment of judgment
• C. The client understands the risks and benefits associated with the procedure
• D. The client has signed the form freely and voluntarily

Correct answer: A

Rationale: The nurse's signature on a surgical consent form signifies that the client voluntarily grants permission for the procedure to be done. This is the correct answer because the nurse's signature does not imply the client's competence, understanding of risks and benefits, or that the client signed the form freely and voluntarily. The nurse's role is to verify that the client has made an informed decision and is providing consent for the procedure.

2. At 42-weeks gestation, a client refuses induction and desires a natural delivery. What is the most important action for the nurse to take?

• A. Discuss alternative ways to support her birth plan.
• B. Explain the indications for induction in post-term pregnancy.
• C. Discuss the differences between labor with oxytocin and natural labor.
• D. Ask the healthcare provider to discuss the issue with the client.

Correct answer: A

Rationale: The correct answer is to discuss alternative ways to support her birth plan. It is crucial to respect the client's autonomy and desires while ensuring their safety and well-being. Choice B is incorrect because while educating the client about the indications for induction is important, it is not the most immediate action to take in this scenario. Choice C is incorrect as it focuses on comparing labor types rather than supporting the client's birth plan. Choice D is incorrect as the nurse should first engage with the client directly before involving the healthcare provider.

3. The nurse is caring for a client receiving a blood transfusion who develops urticaria half an hour after the transfusion has begun. What is the first action the nurse should take?

• A. Stop the infusion
• B. Slow the rate of infusion
• C. Take vital signs and observe for further deterioration
• D. Administer Benadryl and continue the infusion

Correct answer: A

Rationale: The correct action for the nurse to take when a client develops urticaria during a blood transfusion is to immediately stop the infusion. Urticaria is a sign of a transfusion reaction, and stopping the infusion is crucial to prevent the reaction from worsening. Slowing the rate of infusion (Choice B) is not appropriate in this situation as the reaction has already started. While taking vital signs and observing for further deterioration (Choice C) is important, the priority is to stop the transfusion. Administering Benadryl and continuing the infusion (Choice D) is not recommended until the client's condition has stabilized and healthcare provider orders have been obtained.

4. A client is admitted to the hospital with a diagnosis of pneumonia. The client is prescribed intravenous antibiotics and oxygen therapy. Which assessment finding indicates that the client's condition is improving?

• A. Increased white blood cell count
• B. Crackles heard on lung auscultation
• C. Productive cough with green sputum
• D. Decreased respiratory rate from 24 to 18 breaths per minute

Correct answer: D

Rationale: A decrease in respiratory rate indicates that the client's breathing is becoming more stable, which suggests an improvement in their condition. Respiratory rate is a critical indicator of respiratory status and oxygenation. Increased white blood cell count (choice A) suggests ongoing infection, crackles on lung auscultation (choice B) indicate fluid in the lungs, and productive cough with green sputum (choice C) may indicate persistent infection or airway inflammation, which do not necessarily reflect improvement in pneumonia.

5. A client presents with three positive responses to the CAGE questionnaire. What interpretation should the nurse provide?

• A. CAGE is a tool for general substance abuse screening.
• B. Two positive responses suggest alcohol dependence.
• C. One positive response does not indicate alcohol addiction.
• D. All four responses must be positive to suggest alcohol dependence.

Correct answer: B

Rationale: Two positive responses on the CAGE questionnaire strongly suggest alcohol dependence. Choice A is incorrect as the CAGE questionnaire specifically targets alcohol abuse. Choice C is incorrect because one positive response is not enough to indicate alcohol addiction. Choice D is incorrect because alcohol dependence can be suggested with two positive responses, not all four.

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