Nursing Elites

1. Your 54-year-old male HIV-positive patient has just expired. How should you care for this deceased patient?

• A. Bathe the patient, but it is still necessary to use standard precautions because the patient is deceased.
• B. Place the patient in a negative pressure isolated area of the morgue.
• C. Double shroud the patient to prevent the spread of infection.
• D. Bathe the patient using the same standard precautions you used when he was alive.

Correct answer: D

Rationale: Even after a patient has expired, standard precautions should be maintained to prevent the spread of infection. Bathing the deceased patient should be done using the same standard precautions followed when the patient was alive. This includes using personal protective equipment and following proper infection control procedures. Choices A, B, and C are incorrect because standard precautions must still be adhered to even after the patient has passed away to ensure safety and prevent the transmission of infections.

2. 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.

3. Select a myth or falsehood relating to pain, pain management, and addiction.

• A. Addiction can be accurately predicted.
• B. Withdrawal, drug tolerance, and physical dependence do not indicate addiction.
• C. Pain medications should be avoided in patients with a substance abuse history.
• D. Addiction is signaled by deception and stockpiling by the client.

Correct answer: A

Rationale: The correct answer is A because addiction cannot be accurately predicted. Choices B and C are incorrect. Withdrawal, drug tolerance, and physical dependence are not definitive signs of addiction, and pain medications can be used with patients who have a substance abuse history under careful monitoring. Choice D is incorrect because addiction is not solely signaled by deception and stockpiling; it is a complex condition with various behavioral, physical, and psychological aspects.

4. A client with type 1 DM has a finger stick glucose level of 258mg/dl at bedtime. An order for sliding scale insulin exists. The nurse should:

• A. Call the physician
• B. Encourage the intake of fluids
• C. Administer the insulin as ordered
• D. Give the client ½ cup of orange juice

Correct answer: C

Rationale: In this scenario, the client with type 1 DM has a high glucose level at bedtime. The appropriate action for the nurse is to administer the sliding scale insulin as ordered. This insulin regimen is specifically designed to manage high blood glucose levels. Calling the physician is not necessary as the protocol for sliding scale insulin is already in place. Encouraging fluid intake or providing orange juice is not the correct intervention for addressing high blood glucose levels in this case.

5. A nurse working on a med-surg unit is managing the care of four clients. The nurse should schedule an interdisciplinary conference for which of the following clients?

• A. A client who is at risk for pressure ulcers and has an albumin level of 4.2 g/dL
• B. A client with type 1 DM who uses an insulin pump
• C. A client who is receiving heparin and has an aPTT of 34 seconds
• D. A client with orthostatic hypotension receiving IV fluids

Correct answer: C

Rationale: The nurse should schedule an interdisciplinary conference for a client who is receiving heparin and has an aPTT of 34 seconds to ensure comprehensive care coordination. In this case, the need for a conference may be to discuss potential adjustments in heparin therapy, monitor for adverse effects, or ensure proper anticoagulation levels. Choices A, B, and D do not specifically indicate the need for interdisciplinary collaboration related to the client's condition or treatment. Therefore, they are not the priority for scheduling an interdisciplinary conference.

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