Nursing Elites

1. The nurse is planning care for a patient with acute hypernatremia. What should the nurse include in this patient's plan of care? (select one that does not apply)

• A. Reduce IV access
• B. Limit length of visits
• C. Restrict fluids to 1500 mL per day
• D. Conduct frequent neurologic checks

Correct answer: D

Rationale: For a patient with acute hypernatremia, the nurse should include interventions like reducing free water losses, correcting sodium levels slowly, monitoring neurologic status, and ensuring adequate fluid intake. Conducting frequent neurologic checks is essential in assessing the patient's neurological status and detecting any changes promptly. Therefore, this action should not be excluded from the plan of care. Choices A, B, and C are not directly related to managing acute hypernatremia and can be safely excluded from the plan of care. Reducing IV access, limiting length of visits, and restricting fluids to 1500 mL per day are not appropriate actions for managing acute hypernatremia.

2. A client is preparing for an elective mastectomy. The client is wearing a plain gold wedding band. Which of the following is an appropriate procedure for taking care of this client's ring?

• A. Agree to keep the ring for the client until after surgery
• B. Place the ring in the bag with the client's clothing
• C. Tape the ring securely to the client's finger
• D. Place the client's ring in the facility safe

Correct answer: D

Rationale: In this scenario, placing the client's ring in the facility safe is the most appropriate procedure. This ensures the ring is kept secure and prevents any risk of loss or damage during the surgery. Agreeing to keep the ring for the client could raise concerns about accountability, while placing it in the bag with the client's clothing might lead to misplacement. Taping the ring securely to the client's finger is not recommended as it may hinder blood circulation or cause discomfort.

3. A client with a tumor refuses surgery, but the client's partner wants it. Which is the deciding factor in determining if the surgery will be done?

• A. Whether the partner is the client's durable power of attorney for healthcare
• B. Whether the client understands the risk of refusing the procedure
• C. Whether the client's refusal is based on religious belief
• D. Whether the facility's ethical committee reaches a consensus on the case

Correct answer: B

Rationale: The correct answer is B because the client's understanding of the risks involved in refusing the surgery is crucial in determining the course of action. In this scenario, the client's autonomy and decision-making capacity take precedence. Choice A is not directly relevant to the decision-making process regarding surgery. Choice C, religious beliefs, may influence the decision but should not be the determining factor in this case. Choice D involving the facility's ethical committee is not typically involved in individual patient care decisions.

4. A nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which of the following clinical manifestations would the nurse expect to note in the client?

• A. Twitching
• B. Positive Trousseau's sign
• C. Hyperactive bowel sounds
• D. Hyperactive deep tendon reflexes

Correct answer: A

Rationale: The correct answer is A: Twitching. Hypocalcemia often presents with neuromuscular irritability, leading to manifestations such as twitching. Trousseau's sign is actually a positive indicator of hypocalcemia, not negative, making choice B incorrect. Hypoactive bowel sounds are not typically associated with hypocalcemia, making choice C incorrect. Similarly, hypoactive deep tendon reflexes are not a common finding in hypocalcemia, making choice D incorrect.

5. A nurse in the emergency department is assessing a client who is unconscious following a motor-vehicle crash. The client requires immediate surgery. Which of the following actions should the nurse take?

• A. Transport the client to the operating room without verifying informed consent
• B. Ask the anesthesiologist to sign the consent
• C. Obtain telephone consent from the facility administrator before the surgery
• D. Delay the surgery until the nurse can obtain informed consent

Correct answer: A

Rationale: In emergency situations where a client is unconscious and requires immediate surgery, implied consent applies. Implied consent allows healthcare providers, including nurses, to proceed with necessary treatment or surgery without formally verifying informed consent. Choice A is correct because the priority in this scenario is to ensure the client receives timely medical intervention to address life-threatening conditions. Choices B, C, and D are incorrect because in emergencies, waiting to obtain formal consent can delay critical treatment, risking the client's health and well-being.

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