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. Which of the following nursing interventions is appropriate for a client suffering from a fever?

• A. Avoid withholding food from the client
• B. Increase the client's fluid intake
• C. Provide oxygen
• D. All answers are correct

Correct answer: B

Rationale: The appropriate nursing intervention for a client suffering from a fever is to increase the client's fluid intake. A fever can elevate the body's metabolism, leading to increased breathing and heart workload. This can result in fluid loss due to heightened respiration and sweating. Moreover, the augmented heart workload may necessitate more oxygen to maintain tissue perfusion. Providing oxygen and increasing fluid intake help meet the body's heightened demands during a fever. Withholding food from the client is inappropriate as proper nutrition is crucial for recovery, and providing oxygen alone may not address the fluid and metabolic demands associated with fever. Therefore, the correct choice is to increase the client's fluid intake.

3. A client must use a non-rebreathing oxygen mask. Which of the following statements is true regarding this type of mask?

• A. A non-rebreather can provide an FiO2 of 40%.
• B. A client should breathe through his or her mouth when using a non-rebreather.
• C. A non-rebreather offers a reservoir from which the client inhales.
• D. The mask of a non-rebreather should be changed every 3 hours.

Correct answer: A

Rationale: A non-rebreather mask is used for supplemental oxygen delivery for clients experiencing breathing difficulties. The non-rebreather mask includes a one-way valve that allows exhaled air to escape, preventing the rebreathing of carbon dioxide. The client inhales oxygenated air from a reservoir bag attached to the mask, providing high-concentration oxygen therapy. A non-rebreather mask can deliver FiO2 levels of up to 90%, making it an effective intervention for clients requiring high oxygen concentrations. Therefore, the statement that 'A non-rebreather can provide an FiO2 of 40%' is correct. Choices B, C, and D are incorrect because clients should breathe through their nose and mouth, the mask offers a reservoir for inhaling oxygen, and the mask should be assessed and potentially replaced if soiled or damaged, not routinely changed every 3 hours.

4. When escorting a patient to the operating room on a stretcher, what should you do to prevent the patient from falling?

• A. Ensure the safety belt or strap is secured on the patient while escorting them to the operating room
• B. Use a safety belt or strap on the patient throughout their escort to the operating room
• C. Lower the bed position when moving the patient from the bed to the stretcher
• D. All of the above options are correct

Correct answer: B

Rationale: When escorting a patient to the operating room on a stretcher, it is crucial to secure a safety belt or strap on the patient to prevent falls during the transfer. This safety measure is not considered a restraint but a necessary precaution. Lowering the bed position is not necessary; in fact, the bed should be in a high position to align with the stretcher. Locking the wheels of the stretcher is essential to prevent accidents during patient transfer. Therefore, the correct action to prevent falls while moving a patient to the operating room is to use a safety belt or strap on the patient throughout the escort.

5. What consideration is important when caring for a female Muslim patient?

• A. Make eye contact
• B. Provide long-sleeved gowns or allow her to use her own
• C. Touch while talking
• D. Assign male caregivers when possible

Correct answer: B

Rationale: When caring for a female Muslim patient, providing long-sleeved gowns or allowing her to use her own clothing is crucial. Most Muslim women prefer to cover their whole body, even during examinations. Offering long gowns with long sleeves or allowing the patient to use her own clothing respects her cultural and religious preferences. Making eye contact is not a common practice in some Muslim cultures, so it's important to be mindful of this and respect the patient's preferences. Touching while talking may not be culturally appropriate for some Muslim patients, so it's best to avoid it unless necessary. Assigning female caregivers is often preferred to respect the patient's modesty and religious beliefs. If a male caregiver or physician needs to interact with the patient, the patient's husband may request to be present in the room.

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