Nursing Elites

1. A client with a history of alcoholism is admitted with confusion, ataxia, and nystagmus. Which nursing intervention is a priority for this client?

• A. Monitor for signs of alcohol withdrawal.
• B. Administer thiamine as prescribed.
• C. Provide a quiet environment to reduce confusion.
• D. Initiate fall precautions.

Correct answer: B

Rationale: The correct answer is B: Administer thiamine as prescribed. Administering thiamine is crucial in clients with a history of alcoholism to prevent Wernicke's encephalopathy, which is characterized by confusion, ataxia, and nystagmus. Monitoring for signs of alcohol withdrawal (choice A) is important but not the priority. Providing a quiet environment (choice C) and initiating fall precautions (choice D) are important interventions, but administering thiamine takes precedence due to the risk of Wernicke's encephalopathy.

2. The nurse is triaging several children as they present to the emergency room after an accident. Which child requires the most immediate intervention by the nurse?

• A. An 11-year-old with a headache, nausea, and projectile vomiting
• B. A 5-year-old with a broken arm
• C. A 7-year-old with minor abrasions
• D. A 9-year-old with a twisted ankle

Correct answer: A

Rationale: The correct answer is A. Projectile vomiting in a child with a headache could indicate increased intracranial pressure, requiring immediate attention. Choices B, C, and D do not present with symptoms indicating potentially life-threatening conditions that require urgent intervention.

3. During the infusion of a second unit of packed red blood cells, the client's temperature increases from 99 to 101.6 F. Which intervention should the nurse implement?

• A. Stop the transfusion and start a saline infusion.
• B. Administer antipyretics and continue the transfusion.
• C. Monitor the client’s vital signs every 15 minutes.
• D. Notify the healthcare provider and continue the transfusion.

Correct answer: A

Rationale: An increase in temperature during a transfusion may indicate a transfusion reaction, which can be serious. Stopping the transfusion and starting a saline infusion is the priority action to prevent further complications and address the potential adverse reaction. Administering antipyretics (choice B) may mask the symptoms of a transfusion reaction, delaying appropriate treatment. While monitoring vital signs (choice C) is important, stopping the transfusion takes precedence to prevent harm. Notifying the healthcare provider (choice D) is essential but should not delay the immediate intervention of stopping the transfusion and starting a saline infusion.

4. The healthcare provider explains through an interpreter the risks and benefits of a scheduled surgical procedure to a non-English speaking female client. The client gives verbal consent, and the healthcare provider leaves, instructing the nurse to witness the signature on the consent form. The client and the interpreter then speak together in the foreign language for an additional 2 minutes until the interpreter concludes, 'She says it is OK.' What action should the nurse take next?

• A. Ask for a full explanation from the interpreter of the witnessed discussion.
• B. Have the client sign the consent form.
• C. Document the conversation and witness the consent.
• D. Ask the client directly if she has any questions.

Correct answer: A

Rationale: The correct action for the nurse to take next is to ask for a full explanation from the interpreter of the witnessed discussion. Verbal consent is not sufficient; it is crucial to ensure that the client fully comprehends the risks and benefits of the surgical procedure. By asking the interpreter to provide a detailed explanation of the discussion, the nurse can confirm that the client has given informed consent. Having the client sign the consent form (Choice B) without ensuring complete understanding may lead to potential misunderstandings. Documenting the conversation and witnessing the consent (Choice C) is not enough to guarantee the client's comprehension. Asking the client directly if she has any questions (Choice D) may not be effective if language barriers persist.

5. While assisting a male client with muscular dystrophy (MD) to the bathroom, the nurse observes that he is awkward and clumsy. When he expresses his frustration and complains of hip discomfort, which intervention should the nurse implement?

• A. Place a portable toilet next to the bed.
• B. Assist the client with walking exercises.
• C. Provide pain medication as prescribed.
• D. Apply a heating pad to the affected hip.

Correct answer: A

Rationale: Placing a portable toilet next to the bed is the most appropriate intervention in this situation. It reduces the need for the client to walk long distances, thereby preventing falls and reducing discomfort. Choice B, assisting with walking exercises, would not be suitable for a client with muscular dystrophy who is experiencing awkwardness and clumsiness. Choice C, providing pain medication, may address the symptom but does not directly address the issue of reducing the need for walking. Choice D, applying a heating pad, may provide temporary relief but does not address the underlying issue of mobility and fall prevention.

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