Nursing Elites

1. When caring for a client with diabetes insipidus (DI), it is most important for the nurse to include frequent assessment for which conditions in the client’s plan of care?

• A. Dry mucous membranes, hypotension
• B. Decreased appetite, headache
• C. Nausea and vomiting, muscle weakness
• D. Elevated blood pressure, petechiae

Correct answer: A

Rationale: Dry mucous membranes and hypotension are key indicators of dehydration in clients with diabetes insipidus. The excessive urination associated with DI can lead to fluid loss, resulting in dehydration. Therefore, monitoring for signs such as dry mucous membranes and hypotension is crucial to assess the client's hydration status. Choices B, C, and D are not directly related to the characteristic symptoms of DI and are less relevant in the context of this condition. Decreased appetite and headache (Choice B) are nonspecific symptoms that may occur in various conditions. Nausea, vomiting, and muscle weakness (Choice C) are not typical manifestations of DI. Elevated blood pressure and petechiae (Choice D) are not commonly associated with DI; instead, hypotension is more commonly observed due to volume depletion.

2. Prior to surgery, written consent must be obtained. What is the nurse’s legal responsibility with regard to obtaining written consent?

• A. Validate the client's understanding of the surgical procedure to be conducted
• B. Explain the surgical procedure to the client and ensure the client comprehends before signing the consent form
• C. Ensure the client, not a family member, signs the surgical consent form
• D. Confirm that the surgical consent form is signed and included in the client's record

Correct answer: A

Rationale: The nurse's legal responsibility in obtaining written consent is to validate the client's understanding of the surgical procedure to be conducted. This process ensures that the client has been comprehensively informed about the procedure, including its risks, benefits, and alternatives. Choice B is incorrect because it does not emphasize the validation of client understanding, which is crucial for informed consent. Choice C is incorrect as the client, not a family member, should provide consent unless specific circumstances dictate otherwise. Choice D is incorrect because although ensuring the consent form is signed and filed is important, it does not address the primary responsibility of confirming the client's comprehension and ensuring informed consent.

3. In preparing to administer a scheduled dose of intravenous furosemide (Lasix) to a client with heart failure, the nurse notes that the client’s B-Type Naturetic peptide (BNP) is elevated. What action should the nurse take?

• A. Measure the client’s oxygen saturation before taking further action
• B. Administer a PRN dose of nitroglycerin (Nitrostat)
• C. Administer the dose of furosemide as scheduled
• D. Hold the dose of furosemide until contacting the healthcare provider

Correct answer: D

Rationale: Elevated BNP levels in a client with heart failure may indicate worsening heart failure. Therefore, the correct action for the nurse to take when encountering an elevated BNP before administering furosemide is to hold the dose and contact the healthcare provider for further guidance. This precaution is necessary to ensure the client's safety and prevent potential complications. Options A and B are incorrect as they do not address the issue of the elevated BNP, which is crucial in this situation. Option C is also incorrect because administering furosemide without consulting the healthcare provider could be harmful if the client's condition is deteriorating.

4. A heparin infusion is prescribed for a client who weighs 220 pounds. After administering a bolus dose of 80 units/kg, the nurse calculates the infusion rate for the heparin sodium at 18 units/kg/hour. The available solution is Heparin Sodium 25,000 units in 5% Dextrose Injection 250 ml. The nurse should program the infusion pump to deliver how many ml/hour?

• A. 18
• B. 27
• C. 36
• D. 45

Correct answer: B

Rationale: To calculate the infusion rate, first, find the total dose required per hour, which is the patient's weight (220 pounds) multiplied by the prescribed rate (18 units/kg/hour). This equals 3960 units/hour. Next, determine how many ml of the solution contain 25,000 units; this is 250 ml. Divide the total dose required per hour (3960 units) by the units per ml (25,000 units/250 ml) to find how many ml are needed per hour. This results in 27 ml/hour. Therefore, the nurse should program the infusion pump to deliver 27 ml/hour. Choice A (18) is incorrect as it does not account for the concentration of the heparin solution. Choices C (36) and D (45) are incorrect as they do not reflect the accurate calculations based on the patient's weight and the heparin concentration in the solution.

5. Which type of Leukocyte is involved with allergic responses and the destruction of parasitic worms?

• A. Neutrophils
• B. Lymphocytes
• C. Eosinophils
• D. Monocytes

Correct answer: C

Rationale: Eosinophils are the correct answer. Eosinophils are specialized white blood cells that play a crucial role in allergic responses and combating parasitic infections. They release substances to destroy parasites and modulate allergic reactions. Neutrophils (Choice A) are mainly involved in fighting bacterial infections. Lymphocytes (Choice B) play a key role in the immune response, including antibody production, but are not primarily responsible for combating parasites or allergic responses. Monocytes (Choice D) are involved in immune defense, differentiating into macrophages or dendritic cells, but they are not mainly associated with allergic responses or parasitic worm destruction.

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