Nursing Elites

1. Which intervention is most important to include in the plan of care for a client at high risk for the development of postoperative thrombus formation?

• A. Instruct the client in the use of the incentive spirometer.
• B. Elevate the head of the bed during all meals.
• C. Use aseptic technique when changing the dressing.
• D. Encourage frequent ambulation in the hallway.

Correct answer: D

Rationale: Thrombus formation is a risk for clients who are immobile postoperatively. Encouraging frequent ambulation helps to prevent stasis in the lower extremities, reducing the risk of thrombus formation. This intervention promotes circulation and prevents blood clot formation, making it the most important intervention in this situation.

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. A client becomes angry while waiting for a supervised break to smoke a cigarette outside and states, 'I want to go outside now and smoke. It takes forever to get anything done here!' Which intervention is best for the nurse to implement?

• A. Encourage the client to use a nicotine patch.
• B. Reassure the client that it is almost time for another break.
• C. Have the client leave the unit with another staff member.
• D. Review the schedule of outdoor breaks with the client.

Correct answer: D

Rationale: When a client becomes angry while waiting for a supervised break, it is essential to address their concerns effectively. Reviewing the schedule of outdoor breaks with the client provides concrete information, helps manage the client's expectations, and may alleviate their frustration. This intervention promotes transparency and empowers the client by clarifying the timing of their desired break, fostering a therapeutic and collaborative nurse-client relationship. Encouraging the client to use a nicotine patch (Choice A) does not address the client's immediate frustration with the break schedule. Reassuring the client about another break (Choice B) may temporarily placate them but does not address the underlying issue. Having the client leave the unit with another staff member (Choice C) may not be feasible or appropriate at that moment and does not address the client's concerns.

4. During the admission assessment of a terminally ill male client, he states that he is an agnostic. What is the best nursing action in response to this statement?

• A. Provide information about the hours and location of the chapel
• B. Document the statement in the client’s spiritual assessment
• C. Invite the client to a healing service for people of all religions
• D. Offer to contact a spiritual advisor of the client’s choice

Correct answer: B

Rationale: Documenting the client's statement in the spiritual assessment is the best nursing action in response to his disclosure of being an agnostic. This respects the client's beliefs and preferences, ensuring that care is tailored to his individual needs. It also demonstrates a commitment to providing holistic and patient-centered care. Providing information about the chapel's hours and location (choice A) may not align with the client's beliefs as an agnostic. Inviting the client to a healing service (choice C) assumes the client's interest in such activities, which may not be the case. Offering to contact a spiritual advisor (choice D) may not be necessary if the client did not express a desire for it.

5. The healthcare professional is monitoring a client receiving IV potassium chloride. Which assessment finding should prompt the healthcare professional to immediately stop the infusion?

• A. The client reports pain at the IV site
• B. The client’s heart rate is irregular
• C. The client has swelling at the IV site
• D. The client’s blood pressure is elevated

Correct answer: B

Rationale: An irregular heart rate is a critical sign of hyperkalemia, a serious condition that can lead to life-threatening cardiac arrhythmias. Stopping the infusion promptly is crucial to prevent further complications. The healthcare professional should inform the healthcare provider immediately for further evaluation and management. Choice A is incorrect because pain at the IV site is common and may not necessitate stopping the infusion. Choice C is incorrect as swelling at the IV site may indicate a local reaction but is not a reason to stop the infusion. Choice D is incorrect as an elevated blood pressure alone is not a direct indication to stop the infusion of IV potassium chloride.

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