Nursing Elites

1. What action should the nurse implement for a female client with cancer who has a good appetite but experiences nausea whenever she smells food cooking?

• A. Encourage family members to cook meals outdoors and bring the cooked food inside
• B. Advise the client to replace cooked foods with a variety of different nutritional supplements
• C. Assess the client’s mucus membranes and report the findings to the healthcare provider
• D. Instruct the client to take an antiemetic before every meal to prevent excessive vomiting

Correct answer: A

Rationale: The correct action for the nurse to implement is to encourage family members to cook meals outdoors and bring the cooked food inside. This strategy can help reduce the smell of cooking food and potentially alleviate the client's nausea triggered by food smells. Assessing the client's mucus membranes (choice C) is not directly related to the client's symptom of nausea triggered by food smells. Instructing the client to take an antiemetic before every meal (choice D) may not address the root cause of the issue, which is the smell of cooking food. Advising the client to replace cooked foods with nutritional supplements (choice B) does not address the immediate problem of food odors triggering nausea.

2. A male client is returned to the surgical unit following a left nephrectomy and is medicated with morphine. His dressing has a small amount of bloody drainage, and a Jackson-Pratt bulb surgical drainage device is in place. Which intervention is most important for the nurse to include in this client's plan of care?

• A. Monitor urine output hourly
• B. Assess for back muscle aches
• C. Record drainage from the drain
• D. Obtain body weight daily

Correct answer: C

Rationale: The most important intervention for the nurse to include in the client's plan of care following a left nephrectomy with a Jackson-Pratt bulb in place is to record drainage from the drain. Monitoring the drainage is crucial as it helps assess for potential complications such as hemorrhage, infection, or other issues related to the surgical site. Assessing urine output is important post-nephrectomy but not as critical as directly monitoring the drainage. Assessing for back muscle aches may be relevant for pain management but not as crucial as monitoring the drainage. Obtaining body weight daily is not directly related to assessing the surgical drain output and is less critical in this scenario.

3. Which client’s vital signs indicate increased intracranial pressure (ICP) that the nurse should report to the healthcare provider?

• A. P 70, BP 120/60 mmHg; P 100, BP 90/60 mmHg; rapid respirations.
• B. P 55, BP 160/70 mmHg; P 50, BP 194/70 mmHg; irregular respirations.
• C. P 130, BP 190/90 mmHg; P 136, BP 200/100 mmHg; Kussmaul respirations.
• D. P 110, BP 130/70 mmHg; P 100, BP 110/70 mmHg; shallow respirations.

Correct answer: C

Rationale: Choice C is the correct answer. The vital signs presented (P 130, BP 190/90 mmHg; P 136, BP 200/100 mmHg; Kussmaul respirations) indicate increased intracranial pressure (ICP), which can be a serious condition requiring immediate medical attention. Kussmaul respirations are deep and labored breathing patterns associated with metabolic acidosis and can be a late sign of increased ICP. Choices A, B, and D do not demonstrate vital sign patterns consistent with increased ICP. Choice A shows variations in blood pressure and pulse rate but does not provide a clear indication of increased ICP. Choice B displays fluctuations in blood pressure and pulse rate with irregular respirations, but these vital signs do not specifically suggest increased ICP. Choice D presents relatively stable vital signs with shallow respirations, which do not align with the typical vital signs seen in increased ICP.

4. The nurse discontinues a continuous IV heparin infusion for a male client on strict bedrest and is now preparing to administer the client's first dose of enoxaparin. Prior to giving this subcutaneous injection, which assessment finding requires additional intervention by the nurse?

• A. Current lab report indicates an Aptt at 1.5 times the client's control
• B. The client states that his right calf is aching and wants pain medication
• C. The spouse is assisting the client who is shaving with an electric razor
• D. Several bruised areas are noted on the client's upper extremities bilaterally

Correct answer: D

Rationale: The correct answer is D. Bruised areas on the client's upper extremities bilaterally indicate an increased risk of bleeding, which requires careful assessment before administering enoxaparin. Bruising suggests potential issues with clotting and hemostasis, making it crucial for the nurse to further evaluate the client's bleeding risk. Choices A, B, and C do not directly relate to the assessment of bleeding risk associated with enoxaparin administration and are therefore incorrect. Choice A provides information about the client's Aptt, which is not directly relevant to assessing bleeding risk for enoxaparin. Choice B addresses pain management, and Choice C involves the client's daily activities with no direct link to the bleeding risk assessment.

5. Prior to surgery, written consent must be obtained. What is the nurse’s legal responsibility with regard to obtaining written consent?

• A. Validate the client's understanding of the surgical procedure to be conducted
• B. Explain the surgical procedure to the client and ensure the client comprehends before signing the consent form
• C. Ensure the client, not a family member, signs the surgical consent form
• D. Confirm that the surgical consent form is signed and included in the client's record

Correct answer: A

Rationale: The nurse's legal responsibility in obtaining written consent is to validate the client's understanding of the surgical procedure to be conducted. This process ensures that the client has been comprehensively informed about the procedure, including its risks, benefits, and alternatives. Choice B is incorrect because it does not emphasize the validation of client understanding, which is crucial for informed consent. Choice C is incorrect as the client, not a family member, should provide consent unless specific circumstances dictate otherwise. Choice D is incorrect because although ensuring the consent form is signed and filed is important, it does not address the primary responsibility of confirming the client's comprehension and ensuring informed consent.

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