Nursing Elites

1. A client with a diagnosis of Guillain-Barre syndrome is in a non-responsive state, yet vital signs are stable and breathing is independent. What should the nurse document to most accurately describe the client's condition?

• A. Comatose, breathing unlabored
• B. Glasgow Coma Scale 8, respirations regular
• C. Appears to be sleeping, vital signs stable
• D. Glasgow Coma Scale 13, no ventilator required

Correct answer: B

Rationale: The correct answer is B. A Glasgow Coma Scale of 8 with regular respirations accurately describes a non-responsive state with independent breathing. Choice A is incorrect because 'comatose' implies a deeper state of unconsciousness than what is described in the scenario. Choice C is inaccurate as the client is not merely sleeping but non-responsive. Choice D is incorrect as a Glasgow Coma Scale of 13 indicates a higher level of consciousness than what is presented in the scenario.

2. The nurse is discharging an adult woman who was hospitalized for 6 days for treatment of pneumonia. While the nurse is reviewing the prescribed medications, the client appears anxious. What action is most important for the nurse to implement?

• A. Instruct the client to repeat the medication plan
• B. Encourage the client to take a PRN antianxiety drug
• C. Provide written instructions that are easy to follow
• D. Include a family member in the teaching session

Correct answer: D

Rationale: Including a family member in the teaching session is the most important action for the nurse to implement in this scenario. By involving a family member, the nurse can ensure that there is additional support and reinforcement of the medication plan. This can help the client and family better understand and adhere to the prescribed medications, reducing the client's anxiety. Instructing the client to repeat the medication plan (Choice A) may not address the client's anxiety effectively. Encouraging the client to take a PRN antianxiety drug (Choice B) should not be the first intervention without exploring other supportive measures. Providing written instructions (Choice C) alone may not offer the immediate support and reassurance needed for the anxious client.

3. A nurse prepares to admit a client who is immediately postoperative to the unit following abdominal surgery. When transferring the client from the gurney to the bed, what should the nurse do?

• A. Lock the wheels on the bed and gurney
• B. Adjust the bed height
• C. Use a slide sheet
• D. Ask for assistance from another nurse

Correct answer: A

Rationale: The correct action for the nurse to take when transferring a postoperative client from the gurney to the bed is to lock the wheels on both the bed and the gurney. Locking the wheels ensures stability and prevents accidents during the transfer. Adjusting the bed height may be necessary for comfort but is not the primary concern during the transfer process. Using a slide sheet may be helpful in repositioning the client once on the bed but is not essential for the initial transfer. Asking for assistance from another nurse is always a good practice, but the immediate action to ensure safety during the transfer is to lock the wheels.

4. A nurse is caring for a client who has terminal lung cancer. The nurse observes the client’s family assisting with all ADLs. Which of the following rationales for self-care should the nurse communicate to the family?

• A. Allowing the client to function independently will strengthen muscles and promote healing.
• B. The client needs privacy at times for self-reflection and organizing life.
• C. The client’s sense of loss can be lessened through retaining control of some areas of life.
• D. Performing ADLs is a requirement prior to discharge from an acute care facility.

Correct answer: C

Rationale: The correct answer is C. In situations like terminal illness, allowing clients to perform activities of daily living (ADLs) can help maintain their sense of control and dignity, providing comfort and a sense of normalcy amidst their health challenges. Choice A is incorrect because in a terminal stage, the focus is not on muscle strength or promoting physical healing but rather on enhancing the client's emotional well-being. Choice B, while highlighting the importance of privacy, is not directly addressing the client's need for control and autonomy. Choice D is incorrect as the priority in this scenario is not related to discharge requirements but rather the client's emotional and psychological needs during their terminal illness.

5. Heparin 20,000 units in 500 ml D5W at 50 ml/hour has been infusing for 5.5 hours. How much heparin has the client received?

• A. 11,000 units.
• B. 13,000 units.
• C. 15,000 units.
• D. 17,000 units.

Correct answer: A

Rationale: To calculate the total amount of heparin received, multiply the infusion rate (50 ml/hour) by the total infusion time (5.5 hours). This results in 275 ml of the solution infused. Since there are 20,000 units of heparin in 500 ml, there are 800 units per ml. Therefore, 275 ml contains 220,000 units. However, the heparin is diluted in 500 ml, so the client has received half of this amount, which is 110,000 units. Therefore, the correct answer is 11,000 units. Choices B, C, and D are incorrect as they do not reflect the correct calculation based on the provided information.

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