Nursing Elites

1. Which of the following conditions has a severe complication of respiratory failure?

• A. Bell's palsy
• B. Guillain-Barr� syndrome
• C. Trigeminal neuralgia
• D. Tetanus

Correct answer: B

Rationale: Guillain-Barr� syndrome is characterized by a severe complication of respiratory failure due to the involvement of the peripheral nerves that control breathing. While Bell's palsy, trigeminal neuralgia, and tetanus are also conditions affecting peripheral nerves, they do not typically lead to respiratory failure like Guillain-Barr� syndrome. Bell's palsy causes facial muscle weakness, trigeminal neuralgia results in severe facial pain, and tetanus leads to muscle stiffness and spasms, but none of these conditions directly involve respiratory failure.

2. When a client's postoperative pain seems to be getting worse due to grief over the recent death of their spouse, what should the nurse consider?

• A. calling the physician for an increased dosage of pain medication
• B. calling the physician for a sedative
• C. referring the client for a psychiatric consult
• D. developing interventions for grief and loss

Correct answer: D

Rationale: The correct answer is developing interventions for grief and loss. In this scenario, the client's pain is not solely sensory but also affective due to grieving over the death of their spouse. It is essential to address the emotional component of pain by providing support and interventions for grief and loss. Referring the client for a psychiatric consult may not be necessary as grieving is a normal response to such a significant loss. Calling the physician for an increased dosage of pain medication or a sedative solely focuses on the sensory aspect of pain and does not address the underlying emotional distress.

3. The nurse notes that a healthcare provider has documented the following prescription in a client's record: Furosemide (Lasix) 40 mg stat once. What action should the nurse take?

• A. Administering the medication
• B. Drawing up the medication in a syringe
• C. Planning to have the nurse on the next shift administer the medication
• D. Contacting the healthcare provider

Correct answer: D

Rationale: The correct action for the nurse to take in this situation is to contact the healthcare provider. The prescription provided lacks crucial information such as the route of administration. Before administering any medication, the nurse must clarify any missing details with the provider, especially for a stat prescription that requires immediate administration. Drawing up or administering the medication without verifying the route of administration is unsafe and can lead to errors. Planning for the next shift nurse to administer the medication is not appropriate in this scenario as the stat order necessitates immediate action. Therefore, the best course of action is to contact the healthcare provider to obtain clarification on the prescription.

4. Which of the following statements by a client with gastroesophageal reflux disease (GERD) indicates adequate understanding?

• A. "I should eat right before bedtime."?
• B. "I should eat large meals."?
• C. "I should sit up after eating."?
• D. "I should lie flat after eating."?

Correct answer: C

Rationale: The correct statement for a client with GERD is, 'I should sit up after eating.' This helps prevent reflux by keeping the stomach contents down. Choice A is incorrect as eating right before bedtime can exacerbate GERD symptoms by increasing the likelihood of reflux during the night. Choice B is incorrect because consuming large meals can lead to increased stomach pressure and worsen reflux symptoms. Choice D is incorrect because lying flat after eating can promote reflux due to gravity assisting the flow of stomach contents into the esophagus, worsening GERD.

5. Which of these would be the most appropriate way to document a client's refusal of medication?

• A. "Heparin refused during shift. Risks reviewed."?
• B. "The client refused the heparin injection when I tried to administer it. She yelled at me, saying, 'I do not want that injection right now!' and told me to leave the room. I explained the risks of not taking the medication. She seemed very annoyed that I tried to give it at that time. I will attempt again later in my shift."?
• C. "Subcutaneous Heparin injection was attempted to be given to the client per the physician's order. Client refused, stating, 'I do not want that injection.' Potential risks for refusing the medication were reviewed with the client, and the client verbalized understanding."?
• D. "Ct stated she did not want the SQ heparin inj at this time. Risks of not taking this med were reviewed with the ct, and the ct verbalized understanding."?

Correct answer: C

Rationale: The most appropriate way to document a client's refusal of medication should include details such as the medication, the client's statement of refusal, and the review of potential risks. Choice C accurately captures all these essential elements, making it the correct answer. Choice A lacks details about the client's refusal and the review of risks. Choice B includes unnecessary emotional descriptions and a plan of action that might not be appropriate. Choice D uses abbreviations that may not be universally understood, lacks proper punctuation, and also does not provide a detailed account of the refusal and the review of risks.

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