Nursing Elites

1. A client with vision loss is under the care of a nurse. Which of the following actions should the nurse AVOID?

• A. Keep objects in the client's room in the same place
• B. Ensure there is high-wattage lighting in the client's room
• C. Approach the client from the side
• D. Allow extra time for the client to perform tasks

Correct answer: C

Rationale: Approaching a client with vision loss from the side can startle them and may lead to accidents or discomfort. It is important to approach them from the front so they are aware of your presence. Keeping objects in the same place aids in familiarity and reduces the risk of falls. High-wattage lighting enhances visibility for the client. Allowing extra time for tasks accommodates the client's potential slower pace and ensures they can perform tasks safely.

2. A client is to receive thrombolytic therapy. Which of the following factors should be recognized as a contraindication to the therapy?

• A. Hip arthroplasty 2 weeks ago
• B. Elevated sedimentation rate
• C. Incident of exercise-induced asthma 1 week ago
• D. Elevated platelet count

Correct answer: A

Rationale: Thrombolytic therapy involves the use of medications to dissolve blood clots. Hip arthroplasty (joint replacement surgery) performed recently is a contraindication to thrombolytic therapy due to the risk of bleeding. Elevated sedimentation rate, exercise-induced asthma, and elevated platelet count are not contraindications to thrombolytic therapy.

3. A client with tuberculosis is receiving a new prescription for isoniazid (INH). The nurse should instruct the client to report which of the following findings as an adverse effect of the medication?

• A. You might notice yellowing of your skin.
• B. You might experience pain in your joints.
• C. You might notice tingling of your hands.
• D. You might experience loss of appetite.

Correct answer: C

Rationale: Tingling of the hands is a common adverse effect of isoniazid (INH) due to its potential to cause peripheral neuropathy. This sensation can be an early sign of nerve damage, and thus, the client should be instructed to report it promptly to the healthcare provider for further evaluation and management.

4. When preparing an in-service on malpractice issues in nursing, which of the following examples should the nurse include in the teaching?

• A. Leaving a nasogastric tube clamped after administering oral medication
• B. Documenting communication with a provider in the progress notes of the client's medical record
• C. Administering potassium via IV bolus
• D. Placing a yellow bracelet on a client who is at risk for falls

Correct answer: C

Rationale: Administering potassium via IV bolus is a high-risk procedure that requires careful attention and adherence to established protocols to prevent serious complications like cardiac arrest. Errors in administering IV medications, especially potent ones like potassium, can lead to severe harm to the patient and potential legal consequences for the healthcare provider. Therefore, including this example in the in-service on malpractice issues helps emphasize the importance of safe medication administration practices and the potential implications of errors.

5. A client with active tuberculosis is prescribed isoniazid, rifampin, pyrazinamide, and ethambutol. Which statement by the client indicates an understanding of the teaching?

• A. I can substitute one medication for another if I run out because they all fight infection.
• B. I will wash my hands each time I cough.
• C. I am glad I don't have to have any more sputum specimens.
• D. I don't need to worry about where I go once I start taking my medications.

Correct answer: B

Rationale: The correct statement indicating understanding of tuberculosis medication regimen is 'I will wash my hands each time I cough.' This statement shows knowledge of infection control practices to prevent the spread of tuberculosis. Washing hands after coughing helps in reducing the transmission of the disease to others. The other options are incorrect. Option A is incorrect as each medication in the regimen has a specific role, and substituting one for another can compromise the effectiveness of treatment. Option C is incorrect as obtaining sputum specimens is essential for monitoring treatment response. Option D is incorrect as the client should still adhere to infection control measures and avoid exposing others to tuberculosis.

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