Nursing Elites

1. A nurse is caring for her clients when her new admit arrives on the unit. What action by the nurse is most appropriate?

• A. Ask the nursing assistant to complete emptying the catheter bag and assess the new admission.
• B. Ask the nursing assistant to take vital signs on the new admit and begin the history until she can get there.
• C. Ask the graduate nurse on the floor to initiate the assessment process until she can get there.
• D. Ask the unit secretary to make the client and family comfortable until she can complete her present task.

Correct answer: C

Rationale: The most appropriate action for the nurse in this situation is to ask the graduate nurse on the floor to initiate the assessment process until she can arrive. Nursing assistants are not qualified to perform assessments, and the unit secretary's role does not involve client assessments. Delegating the assessment to the graduate nurse ensures that a qualified healthcare professional is evaluating the new admission, aligning with the nurse's responsibilities and providing appropriate care.

2. What is one characteristic of human immunodeficiency virus (HIV)?

• A. The presence of circulating antibodies that neutralize HIV is evidence of exposure to HIV.
• B. HIV replication occurs intracellularly.
• C. HIV integrates its genetic material into the host cell's DNA.
• D. DNA replication is irrelevant to HIV.

Correct answer: C

Rationale: The correct answer is C. HIV integrates its genetic material into the host cell's DNA. The virus uses the enzyme reverse transcriptase to make a DNA copy of its RNA, which is then inserted into the genetic material of the infected cell. Choice A is incorrect because the presence of antibodies does not indicate immunity to HIV but rather exposure to the virus. Choice B is incorrect as HIV replication occurs intracellularly, inside the host cell. Choice D is irrelevant to the characteristics of HIV.

3. Assessment of the client with an arteriovenous fistula for hemodialysis should include:

• A. inspection for visible pulsations.
• B. palpation of thrill.
• C. percussion for dullness.
• D. auscultation of blood pressure.

Correct answer: B

Rationale: The correct answer is to palpate for a thrill. A thrill should be present in a functioning arteriovenous fistula (AVF) and indicates good blood flow. The client should be educated to check for this sensation daily at home to monitor the AVF's patency. Visible pulsations are not typically observed in an AVF. Percussion for dullness does not provide relevant information about the AVF. Auscultation of blood pressure is not a standard practice in assessing an AVF. However, auscultation of the AVF for a bruit, a sound indicating turbulent blood flow, is crucial in evaluating the AVF's patency.

4. A patient 3 hours post-op from a hysterectomy is complaining of intense pain at the incision site. When assessing the patient, the nurse notes a BP of 169/93, pulse 145 bpm, and regular. What action should the nurse take?

• A. Reassure the patient that pain is normal following surgery.
• B. Administer prn Nifedipine and assess the client's response.
• C. Administer prn Meperidine HCL and assess the client's response.
• D. Recheck BP and pulse rate every 20 minutes for the next hour.

Correct answer: C

Rationale: The correct action for the nurse to take in this situation is to administer prn Meperidine HCL and assess the client's response. A BP of 169/93 and a pulse of 145 bpm indicate pain-related hypertension and sinus tachycardia, which are physiological responses to pain. Treating the cause of the increased pulse rate requires pain medication. Reassuring the patient about normal post-surgery pain is important, but addressing the physiological responses to pain is a priority. Administering Nifedipine, a calcium channel blocker, is not indicated for pain management but for hypertension. Rechecking the BP and pulse rate without addressing the pain directly does not address the underlying issue causing the elevated vital signs.

5. The nurse should plan to evaluate the earliest onset of effectiveness of nitroglycerin (Nitrostat) sublingual (SL) within what time frame?

• A. 15 seconds
• B. 3 minutes
• C. 5 minutes
• D. 15 minutes

Correct answer: B

Rationale: The onset of action for Nitrostat SL is 1 to 3 minutes. Therefore, the nurse should plan to evaluate the earliest onset of effectiveness within 3 minutes after administering the medication. Option A, 15 seconds, is too short of a time frame for the onset of action of Nitrostat. Option C, 5 minutes, is slightly delayed compared to the typical onset time. Option D, 15 minutes, is too long to wait for evaluating the effectiveness of Nitrostat sublingual administration.

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