Nursing Elites

1. A client is experiencing suicidal thoughts and states, 'Why not end my misery?' What is the best response by the nurse?

• A. Why do you think your life isn’t worth living anymore?
• B. Do you have a plan to end your life?
• C. I need to understand what you mean by misery.
• D. You can trust me to share your thoughts.

Correct answer: B

Rationale: The correct answer is B: 'Do you have a plan to end your life?' When a client expresses suicidal thoughts, it is crucial to assess the immediate risk. Inquiring about a specific plan can help determine the seriousness of the situation. Choice A is less direct and may not provide a clear indication of the immediate risk. Choice C focuses on the interpretation of 'misery' rather than assessing the risk of suicide. Choice D offers support but does not address the critical assessment of the client's immediate safety.

2. A nurse is caring for a client receiving heparin. Which of the following should the nurse monitor?

• A. INR levels
• B. APTT levels
• C. Blood glucose levels
• D. Liver function tests

Correct answer: B

Rationale: Heparin therapy requires monitoring of activated partial thromboplastin time (APTT) to ensure therapeutic levels. APTT reflects the intrinsic pathway of the clotting cascade and is used to assess the effectiveness and safety of heparin therapy. Monitoring INR levels is more relevant for assessing warfarin therapy, not heparin. Blood glucose levels are monitored for clients with diabetes or those on medications affecting glucose levels. Liver function tests are used to assess liver health and are not directly related to monitoring heparin therapy.

3. A client just received the first dose of lisinopril. Which of the following is an appropriate nursing intervention?

• A. Place the client on cardiac monitoring
• B. Monitor the client's oxygen saturation level
• C. Provide standby assistance when getting out of bed
• D. Encourage foods high in potassium

Correct answer: C

Rationale: The correct answer is to provide standby assistance when getting out of bed. Lisinopril can cause first-dose hypotension, leading to dizziness and increasing the risk of falls. Standby assistance helps ensure the client's safety when mobilizing. Placing the client on cardiac monitoring (choice A) is not necessary unless there are specific indications for cardiac monitoring. Monitoring oxygen saturation (choice B) is not directly related to the side effects of lisinopril. Encouraging foods high in potassium (choice D) is not the most immediate or appropriate intervention following the administration of lisinopril.

4. A nurse is caring for a client who reports burning around the peripheral IV site. Which finding should the nurse identify as a manifestation of infiltration?

• A. Redness at the site
• B. Warmth around the site
• C. Edema
• D. Pain at the site

Correct answer: C

Rationale: Edema at the IV site indicates that IV solution has leaked into the extravascular tissue, which is a sign of infiltration. Redness, warmth, and pain at the site are more indicative of phlebitis, not infiltration. Phlebitis is characterized by redness, warmth, and pain along the vein where the IV is placed, while infiltration involves the leaking of IV fluids into the surrounding tissue.

5. A nurse is caring for a client who is postoperative following a thyroidectomy. The client reports tingling in the fingers and around the mouth. The nurse should anticipate which of the following interventions?

• A. Administer calcium gluconate
• B. Provide a high-protein diet
• C. Administer levothyroxine
• D. Apply a warm compress to the client's neck

Correct answer: A

Rationale: Tingling in the fingers and around the mouth is a sign of hypocalcemia, which can occur after thyroid surgery due to accidental damage to the parathyroid glands. Hypocalcemia is common after thyroidectomy due to potential parathyroid damage. Calcium gluconate is the appropriate intervention to treat hypocalcemia. Providing a high-protein diet or administering levothyroxine are not indicated for hypocalcemia. Applying a warm compress to the client's neck would not address the underlying issue of hypocalcemia.

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