Nursing Elites

1. A client with a do-not-resuscitate (DNR) order has requested resuscitation during a family visit. How should the nurse respond?

• A. Follow the client's wishes and start resuscitation.
• B. Explain that the DNR must be honored.
• C. Ignore the client's request.
• D. Consult with the family regarding the decision.

Correct answer: B

Rationale: The correct answer is B. Nurses have a legal and ethical obligation to honor a client's do-not-resuscitate (DNR) order, regardless of any request for resuscitation during a family visit. It is crucial for the nurse to explain to the client that the DNR order must be respected. Choice A is incorrect because starting resuscitation against the client's documented wishes goes against the principle of autonomy. Choice C is inappropriate as it disregards the client's autonomy and legal directives. Choice D is not the best option as the nurse should prioritize honoring the client's decision as per the DNR order.

2. A patient is receiving an opioid analgesic for pain management. What is the most important assessment for the nurse to perform?

• A. Monitor the patient's blood pressure.
• B. Assess the patient's respiratory rate.
• C. Monitor the patient's oxygen saturation.
• D. Assess the patient's heart rate.

Correct answer: B

Rationale: The correct answer is to assess the patient's respiratory rate. When a patient is receiving opioids, it is crucial to monitor their respiratory rate as opioids can depress the respiratory system, leading to respiratory depression and potential respiratory failure. Monitoring blood pressure, oxygen saturation, and heart rate are important assessments as well, but the priority lies in assessing respiratory rate due to the risk of respiratory depression associated with opioid use.

3. A nurse manager assigns a new nurse to care for a client with unstable blood pressure. What is the nurse's priority action?

• A. Ask the charge nurse for assistance.
• B. Recheck the blood pressure before calling for help.
• C. Monitor the client's blood pressure closely.
• D. Administer antihypertensive medication immediately.

Correct answer: B

Rationale: The correct answer is to recheck the blood pressure before calling for help. When caring for a client with unstable blood pressure, the nurse's priority is to ensure an accurate assessment. Rechecking the blood pressure will confirm the instability and guide further actions. Asking the charge nurse for assistance (Choice A) is important but should come after assessing the situation. Monitoring the client's blood pressure closely (Choice C) is essential, but the immediate action should be to recheck and confirm the current status. Administering antihypertensive medication immediately (Choice D) without a confirmed assessment can be dangerous and is not the initial priority.

4. A healthcare provider is reviewing a client's lab results. Which of the following lab values should the provider report?

• A. Magnesium 1.9 mEq/L
• B. Potassium 3.6 mEq/L
• C. Sodium 126 mEq/L
• D. Chloride 99 mEq/L

Correct answer: C

Rationale: The correct answer is C: Sodium 126 mEq/L. A sodium level of 126 mEq/L is below the normal range, indicating hyponatremia, which can have serious health implications and should be reported to the healthcare provider for further evaluation and intervention. Choices A, B, and D are within or close to the normal ranges for magnesium, potassium, and chloride, respectively, and do not require immediate reporting as they are not significantly abnormal.

5. A client with a new diagnosis of type 1 diabetes mellitus is being taught about self-administration of insulin by a nurse. Which of the following instructions should the nurse include?

• A. Store the current bottle of insulin at room temperature
• B. Massage the injection site after removing the needle
• C. Pull back on the plunger after injecting the insulin
• D. Use each syringe up to six times

Correct answer: A

Rationale: The correct answer is to store the current bottle of insulin at room temperature. Insulin should be stored this way to maintain its potency and effectiveness. Choice B is incorrect because massaging the injection site after removing the needle is not recommended practice and can cause bruising. Choice C is incorrect as pulling back on the plunger after injecting insulin can lead to injecting air bubbles into the tissue. Choice D is incorrect as syringes should not be reused multiple times due to the risk of contamination and inaccurate dosing.

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