Nursing Elites

1. A nurse is caring for a client who has cancer. The client’s adult child asks the nurse for information about the client’s treatment plan. Which of the following responses should the nurse make?

• A. I will ask your mother's primary care provider to speak with you
• B. What would you like to know about your mother's treatment?
• C. I cannot provide this information to you without your mother's consent
• D. You will have to speak directly to your mother about her treatment

Correct answer: C

Rationale: The nurse should not provide treatment information without the client's consent.

2. Ben injects his insulin as prescribed, but then gets busy and forgets to eat. What will the best assessment of the nurse reveal?

• A. The client will be very thirsty.
• B. The client will complain of nausea.
• C. The client will need to urinate.
• D. The client will have moist skin.

Correct answer: D

Rationale: The correct answer is D. In this scenario, since Ben took his insulin but forgot to eat, he is at risk of developing hypoglycemia. Moist skin is a sign of hypoglycemia, which can occur when blood sugar levels drop too low. Thirstiness (choice A) is more commonly associated with hyperglycemia (high blood sugar levels). Nausea (choice B) and frequent urination (choice C) are not typical immediate signs of hypoglycemia caused by missing a meal after insulin administration.

3. A client is in DKA, secondary to infection. As the condition progresses, which of the following symptoms might the nurse see?

• A. Kussmaul's respirations and a fruity odor on the breath
• B. Shallow respirations and severe abdominal pain
• C. Decreased respirations and increased urine output
• D. Cheyne-Stokes respirations and foul-smelling urine

Correct answer: A

Rationale: In diabetic ketoacidosis (DKA), as the condition progresses, the body tries to compensate for the acidic environment by increasing the respiratory rate, leading to Kussmaul's respirations. The accumulation of ketones in the body causes a fruity odor on the breath. Option A is correct because Kussmaul's respirations and a fruity odor on the breath are classic signs of DKA. Option B is incorrect because shallow respirations are not typically seen in DKA, and severe abdominal pain is more commonly associated with conditions like pancreatitis. Option C is incorrect as decreased respirations are not a typical finding in DKA, and increased urine output is more commonly seen in conditions like diabetes insipidus. Option D is incorrect because Cheyne-Stokes respirations are not characteristic of DKA, and foul-smelling urine is not a prominent symptom in this condition.

4. A nurse is preparing to discharge a client who has end-stage heart failure. The client's partner tells the nurse she can no longer handle caring for the client. Which of the following actions should the nurse take?

• A. Request another family member to assist the client's partner with care
• B. Recommend the partner to place the client in a long-term care facility
• C. Contact the case manager to discuss discharge options
• D. Ask the provider to delay the client's discharge home for a few more days

Correct answer: C

Rationale: The nurse should contact the case manager to discuss discharge options and support the client's partner. This action is appropriate as it involves seeking professional guidance and support for the client's partner who is struggling to care for the client. Option A is not the best choice as it solely focuses on involving another family member without addressing the partner's concerns directly. Option B is premature as recommending long-term care should be a well-considered decision involving multiple healthcare professionals. Option D delays the inevitable without providing a solution to the partner's current challenges.

5. A charge nurse making rounds observes that an assistive personnel (AP) has applied wrist restraints to a client who is agitated and does not have a prescription for restraints. Which of the following actions should the nurse take first?

• A. Remove the restraints from the client's wrists
• B. Review the chart for nonrestraint alternatives for agitation
• C. Speak with the AP about the incident
• D. Inform the unit manager of the incident

Correct answer: A

Rationale: The correct action for the nurse to take first is to remove the restraints from the client's wrists. Restraints should not be applied without a prescription due to the risk of harm to the client. Removing the restraints promptly is a priority to ensure the client's safety. Reviewing nonrestraint alternatives, speaking with the AP, and informing the unit manager can follow after ensuring the client's immediate safety by removing the restraints.

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