Nursing Elites

1. A nurse overhears a colleague informing a client that he will administer her medication by injection if she refuses to swallow her pills. The nurse should recognize that the colleague is committing which of the following torts?

• A. Defamation - harming someone's reputation through false statements.
• B. Malpractice - professional negligence or misconduct.
• C. Assault - threatening to cause harm to someone.
• D. Battery - intentional harmful or offensive physical contact.

Correct answer: C

Rationale: In this scenario, the colleague's action of informing the client that he will administer medication by injection if she refuses to swallow her pills constitutes assault. Assault is the act of threatening harm that causes fear of imminent harm. It does not involve physical contact but rather the apprehension of an imminent harmful or offensive act. Defamation, choice A, is incorrect as it involves harming someone's reputation through false statements. Malpractice, choice B, is also incorrect as it refers to professional negligence or misconduct in performing duties. Battery, choice D, is not the correct answer as it involves intentional harmful or offensive physical contact with the person.

2. A nurse observes an assistive personnel (AP) preparing to obtain blood pressure with a regular size cuff for a client who is obese. Which of the following explanations should the nurse give the AP?

• A. Using a cuff that is too small will result in an inaccurately high reading.
• B. Using a cuff that is too large will result in an inaccurately low reading.
• C. The regular size cuff is appropriate for all clients.
• D. You should use a cuff of any size as long as it fits.

Correct answer: A

Rationale: The correct answer is A: 'Using a cuff that is too small will result in an inaccurately high reading.' When obtaining blood pressure for an obese client, it is crucial to use a larger cuff to ensure an accurate reading. Choice B is incorrect because using a cuff that is too large for an obese client would actually result in an inaccurately low reading. Choice C is incorrect as a regular size cuff is not appropriate for obese clients due to their larger arm circumference. Choice D is incorrect because using a cuff of any size as long as it fits is not suitable for obtaining accurate blood pressure readings on an obese client.

3. A client with chronic kidney disease is being assessed. Which of the following laboratory values would be most concerning?

• A. Serum creatinine of 3.0 mg/dL
• B. Serum potassium of 6.5 mEq/L
• C. Blood urea nitrogen (BUN) of 45 mg/dL
• D. Hemoglobin of 10 g/dL

Correct answer: B

Rationale: In a client with chronic kidney disease, elevated serum potassium levels (hyperkalemia) are the most concerning finding. Hyperkalemia can lead to life-threatening cardiac dysrhythmias. Monitoring and managing serum potassium levels are crucial in patients with kidney disease to prevent severe complications. While elevated creatinine (Choice A) and BUN (Choice C) are indicative of impaired kidney function, hyperkalemia poses a more immediate threat to the client's health. Hemoglobin levels (Choice D) can be affected by chronic kidney disease but are not as acutely dangerous as severe hyperkalemia.

4. After a client's death in a long-term care facility, identify the correct sequence of steps for the nurse to perform.

• A. 1) Place a name tag on the body 2) Obtain the pronouncement of death from the provider 3) Remove tubes and indwelling lines 4) Wash the client's body 5) Ask the client's family members if they would like to view the body
• B. 2) Obtain the pronouncement of death from the provider 3) Remove tubes and indwelling lines 4) Wash the client's body 5) Ask the client's family members if they would like to view the body 1) Place a name tag on the body
• C.
• D.

Correct answer: B

Rationale: The correct sequence of steps for the nurse in a long-term care facility after a client's death is as follows: First, obtain the pronouncement of death from the provider. Second, remove tubes and indwelling lines before proceeding to wash the client's body. Third, ask the client's family members if they would like to view the body. Finally, place a name tag on the body. This order ensures that the necessary procedures are followed with respect and consideration for the deceased client and their family. Choice B is correct. Choices A, C, and D are incorrect as they do not follow the appropriate sequence of actions required in this situation.

5. A client with a history of atrial fibrillation is taking digoxin (Lanoxin). Which finding should the healthcare provider be notified of immediately?

• A. Heart rate of 52 beats per minute
• B. Blood pressure of 110/70 mmHg
• C. Blood glucose level of 180 mg/dL
• D. Potassium level of 4.0 mEq/L

Correct answer: A

Rationale: A heart rate of 52 beats per minute is a critical finding in a client taking digoxin, as it may indicate digoxin toxicity. Digoxin can cause bradycardia as a side effect, and a heart rate of 52 bpm warrants immediate attention to prevent adverse outcomes. Monitoring and reporting changes in heart rate are crucial in clients on digoxin therapy to prevent serious complications. The other vital signs and laboratory values provided are within normal ranges or not directly associated with digoxin toxicity in this scenario, making them lower priority for immediate reporting.

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