Nursing Elites

1. While receiving an infusion of cefazolin sodium, the client complained of itchy skin. The nurse observed warm, flushed skin with a red rash on the arms, chest, and back. The health care provider was promptly notified.

• A. The client is apparently allergic to cefazolin sodium, as indicated by warm, flushed skin and a rash on the arms, chest, and back.
• B. The client had an allergy to cefazolin sodium.
• C. The health care provider was notified because a rash developed while the client was receiving cefazolin sodium.
• D. During an infusion of cefazolin sodium, the client complained that his skin was itchy. The client's skin was warm and flushed, with a red rash on the arms, chest, and back. The health care provider was notified.

Correct answer: D

Rationale: Accurate and objective documentation is essential during an incident report. Choice A makes an assumption of allergy based on subjective interpretation, which is not appropriate. Choice B states a conclusion without proper documentation. Choice C is incomplete as it fails to provide a detailed account of the observed symptoms. Choice D offers a precise description of the client's symptoms, actions taken, and notification of the healthcare provider, making it the most suitable documentation choice.

2. Why is client and family communication and education concerning restraints essential?

• A. confuses both groups further
• B. helps with coping and stress levels
• C. encourages cooperation with the client and family
• D. puts the responsibility on the client and family, not the nurse

Correct answer: C

Rationale: Client and family communication and education concerning restraints are essential to encourage cooperation. When the client and family understand the purpose and expected benefits of restraints, they are more likely to cooperate. This understanding can help prevent well-meaning family members from releasing restraints due to confusion or lack of information. Therefore, choice C is correct. Choices A, B, and D are incorrect because confusing both groups further, helping with coping and stress levels, and shifting responsibility to the client and family are not the primary goals of communication and education concerning restraints.

3. A Roman Catholic client is preparing to have magnetic resonance imaging. He wants to wear his metal crucifix pendant while he is receiving the test. Which of the following is an appropriate response by the nurse?

• A. "Because it gives you comfort, you may wear it."?
• B. "It is a violation of religious rights to forbid it."?
• C. "I am sorry, but it is not safe for you to wear the crucifix during this test."?
• D. "You may wear it because it is important to you."?

Correct answer: C

Rationale: No metal objects may be worn while receiving magnetic resonance imaging due to safety risks involved with the strong magnet. The correct response by the nurse should prioritize the safety of the client. Allowing the client to wear the metal crucifix poses a risk of injury or interference with the imaging process. Option A is not appropriate as safety takes precedence over comfort in this situation. Option B is incorrect as it does not address the safety concerns associated with wearing metal objects during an MRI. Option D is also incorrect as it fails to acknowledge the safety issue involved and instead focuses solely on the importance to the client. It is important for the nurse to offer alternative forms of spiritual support that do not pose a risk during the MRI procedure.

4. A new nurse employed at a community hospital is reading the organization's mission statement. The new nurse understands that this statement is written for which purpose?

• A. To outline what the organization plans to accomplish
• B. To identify the policies and procedures of the organization
• C. To describe the benefits available to employees
• D. To define the rules of the organization that the employees must follow

Correct answer: A

Rationale: The correct answer is 'To outline what the organization plans to accomplish.' A mission statement expresses the purpose or reason for an organization's existence, outlining what it aims to achieve. It often includes statements of philosophy, purpose, and goals. This statement serves as a benchmark for evaluating the organization's performance. The mission statement is not meant to identify policies and procedures (Choice B) or describe employee benefits (Choice C). Choice B specifies the administrative guidelines and protocols of the organization, while Choice C pertains to the perks available to employees. Choice D is incorrect as the rules of the organization that employees must follow are usually detailed in employee handbooks or codes of conduct, not in the mission statement.

5. For which condition might a client's antidiuretic hormone (ADH) level be increased?

• A. diabetes mellitus
• B. diabetes insipidus
• C. hypothyroidism
• D. hyperthyroidism

Correct answer: B

Rationale: The correct answer is diabetes insipidus. In this condition, the client's ADH level is increased. Diabetes insipidus is characterized by the inability of the kidneys to conserve water due to either inadequate secretion of ADH (central diabetes insipidus) or the kidneys' inability to respond to ADH (nephrogenic diabetes insipidus). Choices A, C, and D are incorrect. In diabetes mellitus, ADH levels are typically normal or elevated in response to high blood sugar levels. Hypothyroidism is not directly related to ADH secretion. In hyperthyroidism, ADH levels are usually normal or decreased.

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