Nursing Elites

1. The nurse is planning care for a 12-year-old child with sickle cell disease in a vaso-occlusive crisis affecting the elbow. Which one of the following should be the priority?

• A. Limiting fluids
• B. Client-controlled analgesia
• C. Applying cold compresses to the elbow
• D. Performing passive range of motion exercises

Correct answer: B

Rationale: During a vaso-occlusive crisis in sickle cell disease, the priority intervention is effective pain management. Client-controlled analgesia allows the child to self-administer pain relief as needed, promoting comfort and reducing stress. Limiting fluids (choice A) is not appropriate in this scenario as hydration is essential to prevent complications. Cold compresses (choice C) may provide some comfort but do not address the underlying pain. Passive range of motion exercises (choice D) are contraindicated during a vaso-occlusive crisis due to the risk of further pain and tissue damage.

2. A nurse enters a client's room and finds her on the floor. The client's roommate reports that the client was trying to get out of bed and fell over the bedrail onto the floor. Which of the following statements should the nurse document about this incident?

• A. ''Incident report completed.''
• B. ''Client climbed over the bedrails.''
• C. ''Client found lying on the floor.''
• D. ''Client was trying to get out of bed.''

Correct answer: C

Rationale: The correct answer is C: ''Client found lying on the floor.'' In this situation, the nurse should document factual, objective information without making assumptions. Stating that the client was found lying on the floor directly reflects what was observed. Choice A, ''Incident report completed,'' is not a statement about the incident itself and does not provide relevant information. Choice B, ''Client climbed over the bedrails,'' introduces unnecessary speculation and assumption which should be avoided when documenting incidents. Choice D, ''Client was trying to get out of bed,'' focuses on the client's behavior rather than the objective observation of the client's position when found.

3. A client is receiving total parenteral nutrition (TPN). The nurse should monitor the client for which complication?

• A. Hypoglycemia
• B. Hyperglycemia
• C. Hypertension
• D. Hyperkalemia

Correct answer: B

Rationale: Hyperglycemia is the correct complication to monitor for in a client receiving total parenteral nutrition (TPN) due to the high glucose content of the solution. TPN solutions are rich in glucose, so monitoring blood glucose levels is crucial to prevent hyperglycemia. Hypoglycemia (Choice A) is less common with TPN due to the high glucose content, making hyperglycemia a more significant concern. Hypertension (Choice C) and hyperkalemia (Choice D) are not typically associated with TPN administration, making them incorrect choices in this scenario.

4. Which of the following findings contraindicate the use of haloperidol (Haldol) and warrant withholding the dose?

• A. Drowsiness, lethargy, and inactivity
• B. Dry mouth, nasal congestion, and blurred vision
• C. Rash, blood dyscrasias, severe depression
• D. Hyperglycemia, weight gain, and edema

Correct answer: C

Rationale: The correct answer is C: Rash, blood dyscrasias, and severe depression are serious side effects of haloperidol that necessitate withholding the dose and prompt further evaluation. Rash can indicate an allergic reaction, blood dyscrasias are serious blood disorders that can be life-threatening, and severe depression may worsen with haloperidol use. Choices A, B, and D are incorrect because drowsiness, lethargy, inactivity, dry mouth, nasal congestion, blurred vision, hyperglycemia, weight gain, and edema are common side effects of haloperidol that may not necessarily contraindicate its use but should be monitored and managed appropriately.

5. A nurse is developing an individualized plan of care for a patient. Which action is important for the nurse to take?

• A. Establish goals that are measurable and realistic.
• B. Set goals that are a little beyond the capabilities of the patient.
• C. Use the nurse's own judgment and not be swayed by family desires.
• D. Explain that without taking alignment risks, there can be no progress.

Correct answer: A

Rationale: When developing an individualized plan of care for a patient, the nurse must set goals that are specific, measurable, achievable, realistic, and time-bound (SMART). Choice A is correct as it emphasizes the importance of establishing goals that are measurable and realistic, ensuring they are attainable within a specific timeframe. Setting goals that are beyond the capabilities of the patient (Choice B) can lead to frustration and lack of progress. Using only the nurse's judgment and disregarding family desires (Choice C) may not consider important aspects of the patient's social support and preferences. Explaining that progress requires taking alignment risks (Choice D) is not a standard approach in nursing care planning and may confuse the patient or hinder trust in the nurse's decision-making.

Similar Questions