Nursing Elites

1. A 59-year-old male client is brought to the emergency room where he is assessed to have a Glasgow Coma Scale of 3. Based on this assessment, how should the nurse characterize the client's condition?

• A. The client is experiencing increased intracranial pressure
• B. He has a good prognosis for recovery
• C. This client is conscious, but is not oriented to time and place
• D. He is in a coma, and has a very poor prognosis

Correct answer: D

Rationale: A Glasgow Coma Scale of 3 indicates severe neurological impairment, suggesting a deep coma or even impending death. This client's condition is critical, and he has a very poor prognosis. Choice A is incorrect because a GCS of 3 does not directly indicate increased intracranial pressure. Choice B is incorrect as a GCS of 3 signifies a grave neurological status. Choice C is incorrect as a GCS of 3 represents a state of unconsciousness rather than being conscious but disoriented.

2. A client who is HIV positive and taking lamivudine (Epivir) calls the clinic to report a cough and fever. What action should the nurse implement?

• A. Advise the client to come to the clinic for an evaluation
• B. Advise the client to increase fluid intake
• C. Advise the client to take an over-the-counter cough suppressant
• D. Advise the client to rest and call if the fever persists

Correct answer: A

Rationale: The correct action for the nurse to implement in this situation is to advise the client to come to the clinic for an evaluation. Given the client's HIV-positive status and medication, it is crucial to assess the cough and fever promptly to identify the underlying cause. Increasing fluid intake (choice B) may be beneficial but does not address the need for evaluation. Taking an over-the-counter cough suppressant (choice C) may not be appropriate without knowing the cause of the symptoms. Advising the client to rest and call if the fever persists (choice D) delays the necessary evaluation and treatment.

3. A client who has a new prescription for warfarin (Coumadin) asks the nurse how the medication works. What explanation should the nurse provide?

• A. It dissolves blood clots
• B. It prevents the blood from clotting
• C. It thins the blood
• D. It decreases the risk of infection

Correct answer: B

Rationale: The correct answer is B: 'It prevents the blood from clotting.' Warfarin works by inhibiting the synthesis of vitamin K-dependent clotting factors in the liver, thereby preventing the formation of blood clots. Choice A is incorrect because warfarin does not dissolve existing blood clots but prevents new ones from forming. Choice C is partially correct but not as specific as choice B in explaining how warfarin works. Choice D is unrelated to the mechanism of action of warfarin and is incorrect.

4. The nurse in a community health clinic is interviewing a female client who has three children. The client tells the nurse that she has a new man in her life, with whom she is having a sexual relationship, and that they both smoke cigarettes. Which information is most important for the nurse to provide this client?

• A. Oral contraceptives should be started to prevent an unwanted pregnancy
• B. Children are more prone to upper respiratory infections if exposed to smoke at home
• C. Cigarette smoking increases the risk for peptic ulcers and emphysema
• D. A diaphragm and condom provide effective contraception when used together

Correct answer: D

Rationale: The most important information for the nurse to provide the client in this situation is that using both a diaphragm and a condom together provides effective contraception and also protects against sexually transmitted diseases (STDs). While oral contraceptives can help prevent unwanted pregnancies, using a barrier method like a diaphragm and a condom is crucial in this scenario where the client is engaging in a new sexual relationship. Choice B is important information but is not the top priority in this context. Choice C, although relevant, does not address the immediate concern of contraception and STD prevention. Therefore, the correct answer is D.

5. The nurse is preparing to administer a unit of packed red blood cells (PRBCs) to a client. Which action is most important for the nurse to take?

• A. Verify the client's blood type
• B. Ensure the PRBCs are warm
• C. Check the client's vital signs
• D. Obtain the client's consent

Correct answer: A

Rationale: Verifying the client's blood type is crucial before administering PRBCs to ensure compatibility and prevent transfusion reactions. Checking the client's blood type is essential in blood transfusions. Ensuring the PRBCs are warm is not a priority as the temperature should be within a specific range regardless of the client's preference. Checking the client's vital signs is important but not as crucial as verifying the blood type before a blood transfusion. Obtaining the client's consent is important for any procedure but does not directly impact the safety and success of administering PRBCs.

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