Nursing Elites

1. Which client can best be assigned to the newly licensed practical nurse?

• A. The client receiving chemotherapy
• B. The client post-coronary bypass
• C. The client with a TURP
• D. The client with diverticulitis

Correct answer: D

Rationale: The best client to assign to the newly licensed nurse is the most stable client. In this case, the client with diverticulitis is the most stable among the options provided. Clients receiving chemotherapy and those post-coronary bypass require specialized care and attention, making them unsuitable for a newly licensed nurse. The client with a TURP may be at risk of bleeding, needing a nurse experienced in managing such complications. Therefore, the client with diverticulitis is the most appropriate choice for the newly licensed practical nurse.

2. After experiencing a traumatic event like losing a child due to poisoning, a client tells the nurse, 'I don’t want to make any new friends right now.' This is an example of which of the following indicators of stress?

• A. emotional indicator
• B. spiritual indicator
• C. sociocultural indicator
• D. intellectual indicator

Correct answer: C

Rationale: The correct answer is C: sociocultural indicator. In this situation, the client's reluctance to make new friends after experiencing a traumatic event like losing a child due to poisoning reflects a change in their social behavior, which is influenced by sociocultural factors. This response indicates how stress can impact a person's relationships and social interactions. Choice A, emotional indicator, is incorrect because the client's statement is more related to social interactions than emotional expression. Choice B, spiritual indicator, is incorrect as the given scenario does not directly involve spiritual beliefs or practices. Choice D, intellectual indicator, is also incorrect as the client's statement does not reflect cognitive or intellectual changes but rather social aspects affected by the stressful event.

3. The licensed practical nurse assigned to the postpartum unit is preparing to administer Rhogam to a postpartum client. Which woman is not a candidate for RhoGam?

• A. A gravida IV para 3 that is Rh negative with an Rh-positive baby
• B. A gravida I para 1 that is Rh negative with an Rh-positive baby
• C. A gravida II para 0 that is Rh negative admitted after a stillbirth delivery
• D. A gravida IV para 2 that is Rh negative with an Rh-negative baby

Correct answer: D

Rationale: The mothers in answers A, B, and C all require RhoGam as they are Rh negative with an Rh-positive baby or have experienced a stillbirth delivery, making them candidates for RhoGam injection. The mother in answer D is the only one who does not require Rhogam because she is Rh negative with an Rh-negative baby, eliminating the need for RhoGam administration.

4. The nurse is caring for a client scheduled for removal of a pituitary tumor using the transsphenoidal approach. The nurse should be particularly alert for:

• A. Nasal congestion
• B. Abdominal tenderness
• C. Muscle tetany
• D. Oliguria

Correct answer: A

Rationale: During the removal of a pituitary tumor using the transsphenoidal approach, nasal congestion is a significant concern as it can further obstruct the airway. This can be due to mucosal swelling, bleeding, or edema resulting from the surgery. Nasal congestion requires immediate attention to prevent airway compromise. Abdominal tenderness, muscle tetany, and oliguria are not directly associated with the pituitary gland or the transsphenoidal approach, making them incorrect choices. Abdominal tenderness is more common in abdominal or pelvic surgeries due to intra-abdominal issues. Muscle tetany is related to electrolyte imbalances or neuromuscular disorders, not specific to pituitary surgery. Oliguria is a concern in renal-related conditions, not typically in pituitary tumor surgeries.

5. A complication of total parenteral nutrition (TPN) is the development of cholestasis. What is this condition?

• A. an inflammatory process of the extrahepatic bile ducts
• B. an arrest of the normal flow of bile
• C. an inflammation of the gallbladder
• D. the formation of gallstones

Correct answer: B

Rationale: Cholestasis due to TPN administration is an intrahepatic process that interrupts the normal flow of bile. It is characterized by a reduction or stoppage of bile flow. Choice A, an inflammatory process of the extrahepatic bile ducts, refers to cholangitis, not cholestasis. Choice C, an inflammation of the gallbladder, describes cholecystitis, a different condition. Choice D, the formation of gallstones, is not correct as cholestasis is about the flow of bile, not the formation of gallstones.

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