Nursing Elites

1. A client on lithium has diarrhea and vomiting. What should the nurse do first?

• A. Recognize this as a drug interaction
• B. Give the client Cogentin
• C. Reassure the client that these are common side effects of lithium therapy
• D. Hold the next dose and obtain an order for a stat serum lithium level

Correct answer: D

Rationale: Diarrhea and vomiting are manifestations of lithium toxicity. The priority action for the nurse is to hold the next dose of lithium and obtain an order for a stat serum lithium level to confirm toxicity. This ensures patient safety and prevents further harm. Recognizing it as a drug interaction is not the first step in this scenario. Cogentin is used to manage extrapyramidal symptoms (EPS) associated with antipsychotics, not lithium toxicity. Reassuring the client about these symptoms as common side effects of lithium therapy is inappropriate as they indicate a more serious issue than typical side effects like hand tremors, nausea, polyuria, and polydipsia.

2. What question must the nurse ask when formulating a nursing diagnosis?

• A. What diagnosis did the physician make for this client?
• B. What is the issue that I can solve for this client?
• C. What physician orders will resolve this issue?
• D. What underlying disease does this client have?

Correct answer: B

Rationale: When formulating a nursing diagnosis, the nurse should focus on identifying the client's specific health problems that can be addressed through nursing interventions. The correct answer emphasizes the nurse's role in identifying and addressing client-specific issues through nursing care. Choice A is incorrect because nursing diagnoses are distinct from medical diagnoses made by physicians. Choice C is incorrect as it focuses on physician orders rather than the nurse's role in diagnosing and addressing client problems. Choice D is incorrect because it pertains to identifying underlying diseases, which is not the primary focus of nursing diagnoses.

3. The charge nurse is notified that the unit will be receiving an admission of a client from another bed in the hospital in order to make room for others being admitted through the emergency room. The unit is the Women's Health Center of the hospital. Which of the following patients would be most appropriate to be transferred to this unit?

• A. A 26-year-old woman who had a bowel resection
• B. A 40-year-old man who underwent a hernia repair
• C. A 31-year-old woman with septicemia and who is on a ventilator
• D. A 91-year-old man with Alzheimer's disease recovering from a fall

Correct answer: A

Rationale: When deciding on transferring patients between units in a hospital, it is essential to consider the appropriateness of the patient for the receiving unit. The Women's Health Center typically caters to female patients with gynecological or obstetric conditions that do not require intensive monitoring or specialized care. In this scenario, the most suitable patient for transfer to the Women's Health Center would be the 26-year-old woman who had a bowel resection, as her condition aligns more closely with the services provided in that unit. The other options, including a male patient, a critically ill patient on a ventilator, and an elderly patient with Alzheimer's disease, would not be appropriate for transfer to a Women's Health Center due to the specialized care they require, which may not align with the unit's focus and staffing capabilities.

4. Mr. N is a client who entered the hospital with a diagnosis of diabetic ketoacidosis. The nurse enters his room to check his vital signs and finds him breathing at a rate of 32 times per minute; his respirations are deep and regular. Which type of respiratory pattern is Mr. N most likely exhibiting?

• A. Kussmaul respirations
• B. Cheyne-Stokes respirations
• C. Biot's respirations
• D. Cluster breathing

Correct answer: A

Rationale: Mr. N is exhibiting Kussmaul respirations, characterized by rapid, deep, and regular breathing. This type of respiratory pattern is commonly seen in metabolic acidosis, such as in diabetic ketoacidosis. Kussmaul respirations are a form of hyperventilation, leading to the elimination of carbon dioxide from the body. Choice B, Cheyne-Stokes respirations, is characterized by alternating periods of deep, rapid breathing followed by periods of apnea and is not typically associated with diabetic ketoacidosis. Choice C, Biot's respirations, involve irregular breathing patterns with periods of apnea and are not reflective of the described breathing pattern. Cluster breathing, as mentioned in Choice D, is not a recognized term in respiratory patterns and does not describe the breathing pattern observed in Mr. N.

5. A nursing unit is implementing a new electronic charting program for the nursing staff to use. Which of the following best describes a disadvantage of using electronic charting?

• A. The information is more likely to be lost or used inappropriately.
• B. Any provider in the unit can have access to the client's medical records.
• C. The system diminishes communication between nurses and providers.
• D. The program may be confusing and difficult to implement.

Correct answer: D

Rationale: A significant disadvantage of implementing a new electronic charting program is the potential for complexity and difficulty in implementation. Introducing a new system requires time and education for staff to adapt and use it appropriately. Users may experience confusion as they learn to navigate the new charting techniques, which can impact workflow efficiency and accuracy. Option A is incorrect because electronic charting systems are designed to enhance data security and integrity, reducing the risk of information being lost or misused. Option B is incorrect as access control mechanisms can restrict who can view specific patient records. Option C is incorrect as electronic charting systems often facilitate communication between healthcare providers by providing real-time access to patient information.

Similar Questions