Nursing Elites

1. A client in the emergency room enters the care area to start an IV. He finds a man sitting on the table, hunched over, and attempting to take deep breaths. He states, 'my chest hurts so much!' His wife is sitting on a chair in the corner, crying. Which of the following is the first action of the client?

• A. Bring the IV kit and quickly start an IV
• B. Assess his breathing and provide oxygen, if necessary
• C. Administer medication to control chest pain
• D. Talk with his wife and find out why she is crying

Correct answer: B

Rationale: In the above scenario, the first action of the nurse should be to assess the client's airway and breathing. It is crucial to address respiratory status first, as the client appears to be experiencing difficulty breathing. Providing oxygen if necessary can help support oxygenation and alleviate potential respiratory distress. Administering medication for chest pain or starting an IV can come after ensuring adequate oxygenation. Talking with the client's wife, though important for emotional support, is not the priority when the client's respiratory status needs to be assessed and managed promptly.

2. A client with hyperkalemia may exhibit peaked T waves on an electrocardiogram. This manifestation is an early sign of high potassium levels, but the diagnosis should not be based on this aspect alone. Untreated, hyperkalemia can lead to progressively worsening cardiac instability.

• A. A lumbar puncture takes a sample of cerebrospinal fluid from the back, which will be analyzed by the lab.
• B. The physician will insert a needle at the level of L4-L5 in the spinal cord.
• C. The client should lie flat on their back for a specific period following the procedure.
• D. The risks of the procedure include headache, back pain, and infection.

Correct answer: B

Rationale: A lumbar puncture is performed to obtain cerebrospinal fluid for analysis to investigate various conditions affecting the client. During the procedure, the client is typically positioned on their side or sitting leaning over a table with their back rounded. The physician inserts a needle into the back around the L4-L5 vertebrae to collect the sample. Option A is incorrect because a lumbar puncture does not draw blood but instead collects cerebrospinal fluid. Option C is incorrect as the client should not necessarily lie flat for 24 hours post-procedure. Option D is incorrect as the common risks of a lumbar puncture include headache, back pain, and potential infection, not nausea, rash, or hypotension.

3. A client is seen in the emergency room as a victim of suspected domestic violence. The nurse's aide brings the client to a center curtained area, gives her a gown to change into, and asks her to wait for the nurse. What is the most appropriate action of the nurse upon arrival?

• A. Ask the client to undress to assess for injuries
• B. Take the client into a private room
• C. Notify the police to file a report
• D. Notify the house supervisor to keep security on alert

Correct answer: B

Rationale: When dealing with a client suspected of domestic violence, it is crucial to provide privacy and a safe environment. Taking the client into a private room allows for a confidential conversation and assessment without compromising the client's safety or dignity. The nurse should prioritize creating a safe space for the client to share information and receive support. Notification of authorities should only occur once a thorough assessment has been conducted to ensure the client's safety and well-being. Option A is incorrect because asking the client to undress should be done with sensitivity and respect for the client's privacy, focusing on assessing injuries rather than visualizing them. Option C is premature as involving the police should be based on a comprehensive assessment and the client's consent. Option D is not the most immediate and direct action required to address the client's immediate needs in a suspected domestic violence situation.

4. You are taking care of Mary Eden, an elderly and frail 91-year-old resident. She gets confused during evening hours and at times she thinks that she hears her daughter calling her from the other side of the nursing home. Which physical problem places Mary Eden at risk for falls?

• A. Her confusion
• B. Her daughter
• C. Evening hours
• D. Her frailness

Correct answer: D

Rationale: Mary Eden's frail and weak muscles due to her age and physical condition place her at risk for falls. While her confusion can contribute to falls, it is considered an emotional or cognitive issue rather than a physical problem. Her daughter and the evening hours are not physical problems that directly increase her risk of falling.

5. Which example best describes the concept of beneficence?

• A. A nurse provides pain medication for a client in the recovery room who is experiencing pain
• B. A client has an advanced directive in place stating that he does not want intubation if he needs CPR
• C. At the request of the client, a nurse does not inform the family about his cancer diagnosis
• D. A nurse withholds narcotic medication for a client in pain, knowing that he is currently disoriented

Correct answer: A

Rationale: Beneficence is the ethical principle of doing good and acting in the best interest of the client. Providing pain relief to a client in the recovery room who is experiencing pain aligns with beneficence as it promotes the client's well-being and comfort. Choice B is related to autonomy, where the client's wishes regarding treatment are respected. Choice C involves confidentiality and the client's right to privacy. Choice D represents nonmaleficence, as withholding pain medication from a client in pain could cause harm and goes against the principle of doing no harm.

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