Nursing Elites

1. A client arrives at an occupational health clinic after being struck by lightning while working in a truck bed. The client is alert but reports feeling faint. Which assessment will the nurse perform first?

• A. Pulse characteristics
• B. Open airway
• C. Entrance and exit wounds
• D. Cervical spine injury

Correct answer: A

Rationale: Assessing pulse characteristics is the priority in this situation due to the potential impact of lightning as a form of electrical current, which can cause irregular heart rhythms. It is crucial to evaluate the pulse rate and regularity to assess for adequate circulation and potential cardiac issues. Since the client is alert and talking, the airway is likely patent, making assessing the airway less urgent. Entrance and exit wounds and cervical spine injury assessments should follow the evaluation of pulse characteristics to ensure proper circulation and prioritize life-threatening issues first. Checking the pulse first will guide further interventions and help in determining the client's hemodynamic status.

2. Which method is used to verify the placement of a newly inserted central venous access device (CVAD)?

• A. Chest x-ray
• B. Flushing the line with heparin
• C. Withdrawing blood to ensure patency
• D. Chest fluoroscopy

Correct answer: A

Rationale: The correct method to verify the placement of a newly inserted central venous access device (CVAD) is a chest x-ray. This is crucial to detect any potential complications such as pneumothorax, which can occur during subclavian vein catheter insertion. Symptoms of pneumothorax may include shortness of breath and anxiety. Flushing the line with heparin is not used for placement verification, but rather for maintaining patency after verification. Withdrawing blood to ensure patency is done after placement is confirmed, not for initial verification. Chest fluoroscopy may be used during the insertion process but is not typically employed for placement verification.

3. The nurse is preparing to administer 10 mL of liquid potassium chloride through a feeding tube, followed by 10 mL of liquid acetaminophen. Which action should the nurse include in this procedure?

• A. Dilute each of the medications with sterile water prior to administration.
• B. Mix the medications in one syringe before opening the feeding tube.
• C. Administer water between the doses of the two liquid medications.
• D. Withdraw any fluid from the tube before instilling each medication.

Correct answer: C

Rationale: Water should be instilled into the feeding tube between administering the two medications to maintain the patency of the feeding tube and ensure that the total dose of medication enters the stomach and does not remain in the tube. These liquid medications do not need to be diluted when administered via a feeding tube. Mixing the medications in one syringe can lead to interactions or alterations in the medications' properties. Withdrawing any fluid from the tube before instilling each medication can cause inaccurate dosing and incomplete administration. Therefore, the correct action is to administer water between the doses of the two liquid medications to ensure proper delivery and avoid any complications.

4. Which approach would the healthcare provider use when managing the care of a client diagnosed with generalized anxiety disorder (GAD)?

• A. Creating an anxiety-free environment for the client
• B. Assisting the client with the development of healthy, adaptive coping mechanisms
• C. Avoiding triggers that produce anxiety in the client
• D. Providing reinforcement that the client's anxiety issues can be eliminated

Correct answer: B

Rationale: The healthcare provider would assist the client with the development of healthy, adaptive coping mechanisms. GAD is characterized by the maladaptive use of worrying as a coping mechanism. The ultimate goal is for the healthcare provider to help the client replace the ineffective worrying with effective, healthy coping mechanisms. Creating an anxiety-free environment is not feasible or recommended; the goal is to help the client learn to deal with anxiety in a healthy manner. While identifying triggers is important, avoiding all triggers that produce anxiety is often impractical. Providing reinforcement that anxiety issues can be eliminated is not appropriate as anxiety is a normal human experience that needs to be managed effectively rather than eliminated completely.

5. Which basic principle of Alcoholics Anonymous (AA) should a client with alcohol use disorder follow?

• A. Spouses should attend Al-Anon meetings.
• B. It is a commitment to focus on long-term goals.
• C. Amends must be made to each person who has been harmed.
• D. People have the power to overcome alcoholism if they truly want to stop drinking.

Correct answer: C

Rationale: The correct answer is that amends must be made to each person who has been harmed. This principle is reflected in the eighth step of the 12 steps of AA, which involves making a list of all persons harmed and being willing to make amends to them. It is a fundamental principle of AA to address past harms and seek to rectify them. Choice A is incorrect because spouses attending Al-Anon meetings is not a basic principle of AA; it is a support group for family members of individuals with alcohol use disorder. Choice B is incorrect because while focusing on long-term goals can be beneficial, AA emphasizes taking one day at a time rather than committing to long-term goals. Choice D is incorrect because AA teaches that individuals struggling with alcoholism are powerless over their addiction and need to rely on a higher power rather than solely their willpower to overcome it.

Similar Questions