Nursing Elites

1. A client is admitted to a medical unit with the diagnosis of gastritis and chronic heavy alcohol abuse. What should the nurse administer to prevent the development of Wernicke's syndrome?

• A. Lorazepam (Ativan)
• B. Famotidine (Pepcid)
• C. Thiamine (Vitamin B1)
• D. Atenolol (Tenormin)

Correct answer: C

Rationale: Thiamine supplementation is critical in preventing Wernicke's syndrome, especially in clients with chronic alcohol use. Wernicke's syndrome is a neurological disorder caused by thiamine deficiency. Lorazepam is a benzodiazepine used for anxiety and not for preventing Wernicke's syndrome. Famotidine is an H2 blocker used to reduce stomach acid production but does not prevent Wernicke's syndrome. Atenolol is a beta-blocker used for hypertension and angina, not for preventing Wernicke's syndrome.

2. Which behavior is most likely to result in a breach of client confidentiality?

• A. Discussing a client’s condition during a teaching conference for nursing staff caring for the client
• B. Two nurses planning a client’s care while having lunch in the hospital cafeteria
• C. Nursing students on the same team discussing their assigned client’s conditions
• D. A registered nurse privately sharing personal feelings about a client with another nurse on the team

Correct answer: B

Rationale: The correct answer is B. Discussing client information in a public area, such as a cafeteria, may lead to breaches of confidentiality. Choice A involves discussing a client's condition in a professional setting, which is not likely to result in a breach as it is for educational purposes. Choice C involves nursing students discussing their assigned client's conditions, which is common in a learning environment and not necessarily a breach of confidentiality. Choice D involves a private conversation between healthcare professionals, which is less likely to result in a breach compared to discussing in a public area like a cafeteria where non-authorized individuals may overhear the conversation.

3. The nurse implements a tertiary prevention program for type 2 diabetes in a rural health clinic. Which outcome indicates that the program was effective?

• A. Clients who developed disease complications promptly received rehabilitation
• B. More than 50% of at-risk clients were diagnosed early in their disease process
• C. Only 30% of clients did not attend self-management education sessions
• D. Average client scores improved on a specific risk factor knowledge test

Correct answer: A

Rationale: The correct answer is A because in tertiary prevention, the focus is on managing complications and providing rehabilitation. Choice B is more aligned with primary prevention as it focuses on early diagnosis. Choice C's attendance in education sessions is not a direct indicator of managing complications. Choice D's improvement in knowledge does not directly measure the program's effectiveness in managing complications.

4. A male client admitted three days ago with respiratory failure is intubated and receiving 40% oxygen per facemask. Currently, his temperature is 99°F, capillary refill is less than 4 seconds, and respiratory effort is within normal limits. What outcome should the nurse evaluate to measure for successful extubation?

• A. Exhibits adequate tissue perfusion
• B. Remains free of injury
• C. Remains free of infection
• D. Maintains effective breathing pattern

Correct answer: D

Rationale: Successful extubation is primarily measured by the client's ability to maintain an effective breathing pattern. This indicates that the client can adequately oxygenate and ventilate without the need for artificial airway support. Choices A, B, and C are important aspects of patient care but are not the primary outcomes to evaluate for successful extubation. Adequate tissue perfusion, freedom from injury, and prevention of infection are ongoing goals during the client's hospitalization but are not the immediate focus when considering extubation.

5. A child with leukemia is admitted for chemotherapy, and the nursing diagnosis, 'altered nutrition, less than body requirements related to anorexia, nausea, vomiting' is identified. Which intervention should the nurse include in this child's plan of care?

• A. Allow the child to eat foods desired and tolerated
• B. Restrict foods brought from fast food restaurants
• C. Recommend eating the same foods as siblings eat at home
• D. Encourage a variety of large portions of food at every meal

Correct answer: A

Rationale: Allowing the child to choose foods can help improve intake and reduce nausea. Choice A is the correct intervention as it empowers the child to select foods they desire and can tolerate, which is crucial in ensuring adequate nutrition intake. Choice B is incorrect because restricting certain foods can further limit the child's options and may not address the underlying issues. Choice C is incorrect as it doesn't consider the specific needs and preferences of the child with altered nutrition. Choice D is incorrect as encouraging large portions of food at every meal may be overwhelming for a child experiencing anorexia, nausea, and vomiting.

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