Nursing Elites

1. Earlier this morning, an elderly Hispanic female was discharged to a LTC facility. The family members are now gathered in the hallway outside her room. What is the best action?

• A. Ask the family to wait in the cafeteria while the next of kin makes the necessary arrangements
• B. Provide space and privacy for the family to share their concerns about the client’s discharge
• C. Ask the social worker to encourage the family to clear the hallway
• D. Explain to the family the client’s need for privacy so that she can make independent decisions

Correct answer: B

Rationale: In this situation, providing space and privacy for the family allows them to openly discuss their concerns regarding the client’s discharge. It respects the family's need for support, communication, and involvement in the decision-making process, ultimately fostering a more effective and compassionate care environment.

2. A healthcare professional is working in an occupational health clinic when an employee walks in and states that he was struck by lightning while working in a truck. The client is alert but reports feeling faint. Which assessment will the healthcare professional perform first?

• A. Pulse characteristics
• B. Open airway
• C. Entrance and exit wounds
• D. Cervical spine injury

Correct answer: A

Rationale: When a person is struck by lightning, it can cause an electrical shock that may affect the heart rhythm. Therefore, assessing pulse characteristics is crucial as lightning can act as a natural defibrillator. Monitoring the pulse rate and regularity will help determine if there are any cardiac abnormalities that need immediate attention. Open airway, entrance and exit wounds, and cervical spine injury assessments are also important but assessing pulse characteristics takes precedence in this situation to address potential cardiac issues.

3. The nurse is providing discharge teaching to a client with a new prescription for warfarin (Coumadin). Which dietary instruction should the nurse include?

• A. Avoid foods high in vitamin K
• B. Increase intake of leafy green vegetables
• C. Consume a consistent amount of foods high in potassium
• D. Limit intake of high-protein foods

Correct answer: A

Rationale: The correct dietary instruction for a client taking warfarin is to avoid foods high in vitamin K. Warfarin is an anticoagulant that works by inhibiting vitamin K-dependent clotting factors. Consuming foods high in vitamin K, such as leafy green vegetables, can antagonize the effects of warfarin, potentially leading to treatment inefficacy or fluctuations in anticoagulation levels. Therefore, clients on warfarin therapy should be advised to avoid foods high in vitamin K to maintain the effectiveness of the medication. Choices B, C, and D are incorrect because increasing leafy green vegetables (choice B) would introduce more vitamin K, consuming a consistent amount of foods high in potassium (choice C) is not directly related to warfarin therapy, and limiting high-protein foods (choice D) is not a specific concern for clients on warfarin therapy.

4. A client in a long-term care facility reports to the nurse that he has not had a bowel movement in 2 days. Which intervention should the nurse implement first?

• A. Instruct the caregiver to offer a glass of warm prune juice at mealtimes.
• B. Notify the healthcare provider and request a prescription for a large-volume enema.
• C. Assess the client's medical record to determine the client's normal bowel pattern.
• D. Instruct the caregiver to increase the client's fluids to five 8-ounce glasses per day.

Correct answer: C

Rationale: When a client reports a change in bowel habits, the first step for the nurse is to assess the client's normal bowel pattern by reviewing the medical records. This assessment helps the nurse understand the client's baseline, which is crucial before initiating any interventions. By determining the client's usual bowel habits, the nurse can identify deviations from the norm and make informed decisions on the appropriate course of action. Assessing the client's medical record is a critical first step in addressing the client's bowel concerns. Choices A, B, and D are incorrect because they jump to interventions without first establishing the client's normal bowel pattern. Offering warm prune juice, requesting a large-volume enema, or increasing fluids may not be appropriate until the nurse knows the client's regular bowel habits and can assess the situation effectively.

5. A client with a history of diabetes mellitus is admitted with a blood glucose level of 600 mg/dL. What type of insulin should the nurse prepare to administer to this client?

• A. Regular insulin
• B. NPH insulin
• C. Lispro insulin
• D. Glargine insulin

Correct answer: A

Rationale: In a client with a blood glucose level of 600 mg/dL, which indicates severe hyperglycemia or diabetic ketoacidosis, the nurse should prepare to administer regular insulin (A). Regular insulin has a rapid onset of action and is the preferred choice for immediate correction of high blood glucose levels. NPH insulin (B), lispro insulin (C), and glargine insulin (D) are not suitable for the rapid correction of severe hyperglycemia.

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