Nursing Elites

1. A client has been administered ketamine by a physician in preparation for general anesthesia. Which of the following side effects should the nurse monitor for in this client?

• A. Delirium
• B. Muscle rigidity
• C. Hypotension
• D. Pinpoint rash

Correct answer: A

Rationale: Ketamine is an anesthetic that induces dissociation and lack of awareness in a client. It can be used before general anesthesia or during short procedures for sedation. Ketamine may lead to side effects such as delirium, hallucinations, hypertension, and respiratory depression. Therefore, the nurse should monitor the client for delirium, as it is a potential side effect associated with ketamine use. Muscle rigidity, hypotension, and pinpoint rash are not typically attributed to ketamine administration and are less likely to occur in this scenario.

2. When should discharge training and planning begin for a 65-year-old man admitted to the hospital for spinal stenosis surgery?

• A. Following surgery
• B. Upon admission
• C. Within 48 hours of discharge
• D. Preoperative discussion

Correct answer: B

Rationale: Discharge training and planning should begin upon admission for a patient undergoing spinal stenosis surgery. It is crucial to initiate this process early to ensure a smooth transition from hospital care to home or a rehabilitation facility. Starting discharge planning upon admission allows for comprehensive involvement of the patient, family, and healthcare team, which can reduce the risk of readmission, optimize recovery, ensure proper medication management, and adequately prepare caregivers. Therefore, option B, 'Upon admission,' is the correct answer. Options A, C, and D are incorrect because waiting until after surgery, within 48 hours of discharge, or during preoperative discussion would not provide sufficient time for effective discharge planning and education.

3. Which of these devices is considered a protective device, rather than a restraint?

• A. A mitten on the hands to prevent scratching
• B. A mitten on the hands to prevent the person from pulling their IV out
• C. A side rail to prevent the patient from falling
• D. A soft wrist restraint to prevent the patient from pulling their IV tubing

Correct answer: A

Rationale: A mitten on the hands to prevent scratching is considered a protective device because its primary purpose is to protect the patient from harming themselves by scratching. It does not restrict the patient's movement. Choice B, a mitten on the hands to prevent the person from pulling their IV out, is considered a restraint as it limits the patient's movement. Choice C, a side rail to prevent the patient from falling, is also a protective device as it aims to keep the patient safe by providing support and preventing falls. Choice D, a soft wrist restraint to prevent the patient from pulling their IV tubing, is a type of restraint as it restricts the patient's movement to prevent them from interfering with medical equipment.

4. The nurse is assessing an infant with developmental dysplasia of the hip. Which finding would the nurse anticipate?

• A. Unequal leg length
• B. Limited adduction
• C. Diminished femoral pulses
• D. Symmetrical gluteal folds

Correct answer: A

Rationale: The correct answer is 'Unequal leg length.' Shortening of a leg is a common sign of developmental dysplasia of the hip. Limited adduction (Choice B) may be present but is less specific to developmental dysplasia of the hip. Diminished femoral pulses (Choice C) are not typically associated with developmental dysplasia of the hip. Symmetrical gluteal folds (Choice D) are a normal finding and would not be expected in a patient with developmental dysplasia of the hip.

5. What consideration is important when caring for a female Muslim patient?

• A. Make eye contact
• B. Provide long-sleeved gowns or allow her to use her own
• C. Touch while talking
• D. Assign male caregivers when possible

Correct answer: B

Rationale: When caring for a female Muslim patient, providing long-sleeved gowns or allowing her to use her own clothing is crucial. Most Muslim women prefer to cover their whole body, even during examinations. Offering long gowns with long sleeves or allowing the patient to use her own clothing respects her cultural and religious preferences. Making eye contact is not a common practice in some Muslim cultures, so it's important to be mindful of this and respect the patient's preferences. Touching while talking may not be culturally appropriate for some Muslim patients, so it's best to avoid it unless necessary. Assigning female caregivers is often preferred to respect the patient's modesty and religious beliefs. If a male caregiver or physician needs to interact with the patient, the patient's husband may request to be present in the room.

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