Nursing Elites

1. A client with a history of chronic alcoholism is admitted with confusion, ataxia, and diplopia. 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 to administer thiamine as prescribed. This intervention is a priority for clients with chronic alcoholism to prevent Wernicke's encephalopathy, a serious complication of thiamine deficiency. Monitoring for signs of alcohol withdrawal (choice A) is important but not the priority in this scenario. Providing a quiet environment (choice C) may be beneficial but does not address the immediate need to prevent Wernicke's encephalopathy. Initiating fall precautions (choice D) is also important but not the priority compared to administering thiamine to prevent a life-threatening condition.

2. To reduce the risk of being named in a malpractice lawsuit, which action is most important for the nurse to take?

• A. Adhere consistently to standards of care.
• B. Thoroughly document all client interactions.
• C. Build a good rapport with clients.
• D. Work closely with the healthcare team.

Correct answer: A

Rationale: Adhering consistently to standards of care is crucial for nurses to reduce the risk of being named in a malpractice lawsuit. Following established protocols and guidelines ensures that the care provided is safe and effective. Thoroughly documenting all client interactions is also essential to support the care provided and to have a record of the interventions. Building a good rapport with clients is important for communication and trust but does not directly reduce the risk of malpractice. Working closely with the healthcare team is valuable for collaboration but might not directly impact the risk of malpractice unless it relates to following standards of care.

3. A client with a history of atrial fibrillation is admitted with a new onset of confusion. Which intervention should the nurse implement first?

• A. Obtain a blood glucose level.
• B. Administer an anticoagulant as prescribed.
• C. Perform a neurological assessment.
• D. Administer aspirin as prescribed.

Correct answer: C

Rationale: Performing a neurological assessment is the priority in this situation as it helps in evaluating the cause of the new onset of confusion in a client with atrial fibrillation. This assessment will provide crucial information about the client's neurological status, which can guide further interventions. Obtaining a blood glucose level (Choice A) is important but should not be the first step when dealing with a new onset of confusion. Administering an anticoagulant (Choice B) or aspirin (Choice D) may be necessary depending on the underlying cause, but assessing the neurological status comes first to determine the appropriate course of action.

4. A female client reports that she drank a liter of a solution to cleanse her intestines but vomited immediately. How many ml of fluid intake should the nurse document?

• A. 240 ml
• B. 500 ml
• C. 760 ml
• D. 1000 ml

Correct answer: C

Rationale: The correct answer is 760 ml. After vomiting 240 ml (1 cup), the nurse should document the remaining 760 ml as the fluid intake. Choice A (240 ml) is the amount vomited, not the total intake. Choice B (500 ml) and Choice D (1000 ml) are the total intake, not considering the vomiting.

5. The healthcare provider prescribes atenolol 50 mg daily for a client with angina pectoris. Which finding should the nurse report to the healthcare provider before administering this medication?

• A. Irregular pulse.
• B. Tachycardia.
• C. Chest pain.
• D. Urinary frequency.

Correct answer: A

Rationale: The correct answer is A: Irregular pulse. An irregular pulse may indicate an arrhythmia, which could be exacerbated by atenolol, a beta-blocker used to treat angina pectoris. Atenolol works by slowing the heart rate, so if the patient already has an irregular pulse, it could worsen with the medication. Tachycardia (choice B) would actually be an expected finding in a patient with angina pectoris, and atenolol is used to help reduce the heart rate in such cases. Chest pain (choice C) is a symptom that atenolol is meant to alleviate, so it would not be a reason to withhold the medication. Urinary frequency (choice D) is not directly related to the administration of atenolol for angina pectoris and would not require immediate reporting to the healthcare provider.

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