Nursing Elites

1. An angry client screams at the emergency department triage nurse, “I’ve been waiting here for two hours! You and the staff are incompetent”. What is the best response for the nurse to make?

• A. The emergency department is very busy at this time.
• B. I’ll let you see the doctor next because you’ve waited so long.
• C. I’m doing the best I can for the sickest clients first.
• D. I understand you are frustrated with the wait time.

Correct answer: D

Rationale: Correct Answer: The best response for the nurse is to choose option D, 'I understand you are frustrated with the wait time.' This response demonstrates empathy and validates the client's feelings, helping to defuse the situation. Choice A is not the best response as it does not directly address the client's emotions or concerns. Choice B is inappropriate as it gives preferential treatment based on the client's behavior. Choice C, while true, does not acknowledge the client's frustration or offer empathy.

2. After an unsuccessful resuscitation attempt, the nurse calls the family of the deceased. The family wishes to see the body before it is taken to the funeral home. Which interventions should the nurse take to prepare the body before the family enters the room? (Select all that apply)

• A. Take out dentures and place them in a labeled cup
• B. Apply a body shroud
• C. Place a small pillow under the head
• D. Gently close the eyes

Correct answer: A

Rationale: The correct interventions for the nurse to prepare the body before the family enters the room include taking out dentures and placing them in a labeled cup. This is essential to ensure the dignity of the deceased and maintain their appearance. Applying a body shroud is not typically done before the family views the body, as it may be more appropriate during preparation for transportation to the funeral home. Placing a small pillow under the head and gently closing the eyes are actions that can be comforting but are not essential preparations for the family viewing.

3. A client diagnosed with a deep vein thrombus (DVT) followed by a diagnosis of pulmonary embolism (PE) is receiving heparin via an infusion pump at a rate of 1400 u/hour. The client tells the nurse, “I wish this medicine would hurry up and dissolve this clot in my lung so that I can go home”. What response is best for the nurse to provide?

• A. Heparin prevents further clot formation, but your risk of bleeding needs to be monitored closely
• B. You seem to be concerned about the length of time it takes for Heparin to dissolve this clot
• C. Let me contact your healthcare provider to discuss the possibility of receiving IV heparin therapy at home
• D. Why are you so anxious to leave the hospital when you know you are not well enough yet?

Correct answer: A

Rationale: The correct response is A: 'Heparin prevents further clot formation, but your risk of bleeding needs to be monitored closely.' Heparin is an anticoagulant that prevents further clot formation, but it does not quickly dissolve existing clots. It is crucial for the nurse to educate the client about the purpose of heparin and the necessity for close monitoring of bleeding risks. Choice B is incorrect as it does not address the misunderstanding about heparin's mechanism of action. Choice C is incorrect as home administration of IV heparin therapy requires careful consideration and should not be suggested without a thorough assessment. Choice D is incorrect as it does not address the client's misconception about heparin's role in dissolving clots and instead focuses on the client's desire to leave the hospital.

4. A client complains of paresthesia in the fingers and toes and experiences hand spasms when the blood pressure cuff is inflated. Which serum laboratory finding should the nurse expect to find when assessing the client?

• A. Elevated serum calcium
• B. Low serum magnesium
• C. Low serum calcium
• D. Elevated serum potassium

Correct answer: C

Rationale: The correct answer is C: Low serum calcium. Hand spasms and paresthesia are indicative of potential hypocalcemia, which is characterized by low serum calcium levels. Elevated serum calcium (Choice A) is not consistent with the symptoms described. Low serum magnesium (Choice B) and elevated serum potassium (Choice D) are not typically associated with hand spasms and paresthesia.

5. After removing an IV that became infiltrated in the client’s left forearm, which site should the nurse select as a possible site to insert another IV catheter?

• A. Right hand
• B. Right forearm
• C. Left hand
• D. Right subclavian

Correct answer: A

Rationale: The correct answer is A: Right hand. When an IV becomes infiltrated in the client's left forearm, it is essential to avoid the same side due to the risk of complications. Therefore, the right hand is a suitable alternative site for IV insertion. Choices B, C, and D are incorrect. Choosing the right forearm (B) would still be on the same side, which increases the risk of complications. The left hand (C) is not a preferred option immediately after an infiltration in the left forearm. The right subclavian (D) is an invasive site typically reserved for central line placement and not a first-line choice for IV insertion.

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