Nursing Elites

1. When escorting a patient to the operating room on a stretcher, what should you do to prevent the patient from falling?

• A. Ensure the safety belt or strap is secured on the patient while escorting them to the operating room
• B. Use a safety belt or strap on the patient throughout their escort to the operating room
• C. Lower the bed position when moving the patient from the bed to the stretcher
• D. All of the above options are correct

Correct answer: B

Rationale: When escorting a patient to the operating room on a stretcher, it is crucial to secure a safety belt or strap on the patient to prevent falls during the transfer. This safety measure is not considered a restraint but a necessary precaution. Lowering the bed position is not necessary; in fact, the bed should be in a high position to align with the stretcher. Locking the wheels of the stretcher is essential to prevent accidents during patient transfer. Therefore, the correct action to prevent falls while moving a patient to the operating room is to use a safety belt or strap on the patient throughout the escort.

2. A client is preparing to undergo a cystoscopy for stones. Which of the following statements indicates that the client understands the procedure?

• A. I better drink a lot of fluid now because I won't be able to after the test.
• B. I will probably see a little blood when I urinate.
• C. I will be able to go home after 3 days in the hospital.
• D. I won't need any pain medicine; this probably will not hurt.

Correct answer: B

Rationale: The correct answer is, 'I will probably see a little blood when I urinate.' During a cystoscopy, a scope is inserted into the client's bladder to inspect structures or remove objects like stones. This procedure is usually performed under local or general anesthesia. It is common for clients to experience a small amount of blood in their urine (hematuria) or have pink-colored urine after the procedure. The other choices are incorrect because drinking a lot of fluid before the test, staying in the hospital for 3 days, and assuming no pain will be experienced are not accurate statements related to a cystoscopy procedure.

3. A client is diagnosed with schizophrenia. A physician orders haloperidol (Haldol) 50 mg bid, benztropine (Cogentin) 1 mg prn, and zolpidem (Ambien) 10 mg HS. Which client behavior would warrant the nurse to administer benztropine?

• A. Tactile hallucinations
• B. Tardive dyskinesia
• C. Restlessness and muscle rigidity
• D. Reports of hearing disturbing voices

Correct answer: C

Rationale: Benztropine (Cogentin) is an anticholinergic medication used to treat extrapyramidal symptoms, such as restlessness and muscle rigidity, which are common side effects of antipsychotic medications like haloperidol. Tactile hallucinations and reports of hearing disturbing voices are symptoms of schizophrenia that would typically be addressed by the antipsychotic medication (haloperidol) itself. Tardive dyskinesia, a potential side effect of long-term antipsychotic use, would require discontinuation of the antipsychotic medication rather than administration of benztropine.

4. A client is admitted with the diagnosis of pulmonary embolism. While taking a history, the client tells the nurse he was admitted for the same thing twice before, the last time just 3 months ago. The nurse would anticipate the healthcare provider ordering:

• A. Pulmonary embolectomy
• B. Vena caval interruption
• C. Increasing the coumadin therapy to achieve an INR of 3-4
• D. Thrombolytic therapy

Correct answer: B

Rationale: In the case of a client with a history of recurrent pulmonary embolism or contraindications to heparin, vena caval interruption may be necessary. Vena caval interruption involves placing a filter device in the inferior vena cava to prevent clots from traveling to the pulmonary circulation. Pulmonary embolectomy is a surgical procedure to remove a clot from the pulmonary artery, which is usually considered in severe or life-threatening cases. Increasing coumadin therapy to achieve a higher INR may be an option but vena caval interruption would be more appropriate in this scenario. Thrombolytic therapy is used in acute cases of pulmonary embolism to dissolve the clot rapidly, but in a recurrent case with contraindications to anticoagulants, vena caval interruption would be a preferred intervention.

5. A patient diagnosed with a mild anxiety disorder has been referred to treatment in a community mental health center. Treatment most likely provided by the center includes

• A. Medical management of symptoms
• B. Daily psychotherapy
• C. Constant staff supervision
• D. Psychological stabilization

Correct answer: A

Rationale: Community mental health centers focus on rehabilitation, vocational needs, education, and socialization, as well as on the management of symptoms and medication. For a patient with a mild anxiety disorder, the primary focus would be on providing medical management of symptoms, such as prescribing appropriate medications and monitoring their effectiveness. Daily psychotherapy is not typically provided in community mental health centers for mild cases, as it may not be necessary. Constant staff supervision and psychological stabilization are more suited for patients requiring a higher level of care or in acute settings where continuous monitoring and stabilization are essential.

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