Nursing Elites

1. A client requests the creation of a living will. Which of the following actions should the nurse take?

• A. Schedule a meeting between the hospital ethics committee and the client
• B. Evaluate the client's understanding of life-sustaining measures
• C. Determine the client's preferences about post-mortem care
• D. Request a conference with the client's family

Correct answer: B

Rationale: The correct action for the nurse to take when a client requests the creation of a living will is to evaluate the client's understanding of life-sustaining measures. This step is crucial to ensure that the client is well-informed about their options before making decisions regarding their future care. Scheduling a meeting with the hospital ethics committee (choice A) may not be necessary at this stage and could overwhelm the client. Determining the client's preferences about post-mortem care (choice C) is not directly related to creating a living will. Requesting a conference with the client's family (choice D) may be important later but is not the initial step in this situation.

2. A client with a history of angina reports substernal chest pain that radiates to the left arm. Which of the following actions should the nurse take first?

• A. Administer nitroglycerin sublingually.
• B. Administer 2L of oxygen via nasal cannula.
• C. Administer aspirin 325 mg orally.
• D. Obtain a 12-lead ECG.

Correct answer: D

Rationale: In a client with a history of angina experiencing chest pain radiating to the left arm, obtaining a 12-lead ECG is the priority action to assess for myocardial infarction. An ECG helps in diagnosing and evaluating the extent of cardiac ischemia or infarction. Administering nitroglycerin, oxygen, or aspirin can follow once the ECG has been performed to confirm the diagnosis and guide further interventions. Administering nitroglycerin sublingually is often appropriate for angina but should not precede the ECG in this urgent scenario. Oxygen therapy and aspirin administration are important interventions but obtaining the ECG takes precedence in assessing for acute cardiac events.

3. What is the priority nursing intervention for a patient with hyperkalemia?

• A. Administer calcium gluconate
• B. Administer insulin
• C. Administer sodium bicarbonate
• D. Administer a diuretic

Correct answer: A

Rationale: The correct answer is to administer calcium gluconate. In hyperkalemia, the priority is to protect the heart from potential complications like arrhythmias. Calcium gluconate is the first-line treatment as it stabilizes the cardiac cell membrane. Insulin (Choice B) and sodium bicarbonate (Choice C) can be used in conjunction with other treatments to shift potassium into cells, but calcium gluconate is the priority. Administering a diuretic (Choice D) is not the primary intervention for hyperkalemia and can even worsen the condition by reducing potassium excretion.

4. How should a healthcare provider care for a patient with a tracheostomy?

• A. Clean the tracheostomy site daily
• B. Change the tracheostomy ties daily
• C. Suction the tracheostomy regularly
• D. Provide humidified oxygen

Correct answer: C

Rationale: Suctioning the tracheostomy regularly is crucial in caring for a patient with a tracheostomy as it helps keep the airway clear of secretions, preventing blockages and potential complications. Cleaning the tracheostomy site daily is important for hygiene but not as critical as regular suctioning. Changing the tracheostomy ties daily may not be necessary unless soiled or loose. Providing humidified oxygen may be part of the care plan but is not as directly related to maintaining the tracheostomy patency as suctioning.

5. A nurse is teaching a client who has heart failure about managing fluid intake. Which of the following instructions should the nurse include?

• A. Drink 2 liters of water per day.
• B. You should restrict your fluid intake to 1 liter per day.
• C. You can drink as much fluid as you want throughout the day.
• D. Limit your fluid intake to 3 liters per day.

Correct answer: B

Rationale: The correct answer is B: "You should restrict your fluid intake to 1 liter per day." Clients with heart failure should limit their fluid intake to prevent fluid overload, which can worsen their condition. Choice A is incorrect because 2 liters of water per day may be excessive for someone with heart failure. Choice C is incorrect as unlimited fluid intake is not suitable for individuals with heart failure. Choice D is also incorrect as 3 liters per day may be too much fluid for a client with heart failure.

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