Nursing Elites

1. The nurse is administering the 0900 medications to a client who was admitted during the night. Which client statement indicates that the nurse should further assess the medication order?

• A. At home, I take my pills at 8:00 am.
• B. It costs a lot of money to buy all of these pills.
• C. I get so tired of taking pills every day.
• D. This is a new pill I have never taken before.

Correct answer: D

Rationale: The client stating, 'This is a new pill I have never taken before,' is the correct answer as it indicates a potential discrepancy in the medication order. This statement requires further assessment to ensure the medication is correct, verify if it is a new prescription or a different manufacturer, and determine if the client needs additional instructions. While the timing of medication administration (option A) is important, it may not be as critical as ensuring the accuracy of the medication being administered. Option B, regarding the cost of pills, is relevant for discharge planning but does not directly impact the immediate administration of the medication. Option C, expressing tiredness from taking pills daily, may warrant discussion on adherence or side effects but does not raise immediate concerns about the specific medication being administered.

2. The nurse is caring for a newly admitted patient. Which intervention is the best example of a culturally appropriate nursing intervention?

• A. Insist that family members provide most of the patient's personal care.
• B. Maintain a personal space of at least 2 feet when assessing the patient.
• C. Ask permission before touching a patient during the physical assessment.
• D. Consider the patient's ethnicity as an important factor in planning care.

Correct answer: C

Rationale: Culturally appropriate nursing care requires sensitivity to the beliefs and practices of diverse cultural groups. Asking permission before touching a patient during a physical assessment is a universally respectful practice, as many cultures consider it disrespectful to touch a person without consent. This approach demonstrates respect for the patient's autonomy and cultural preferences. Maintaining a personal space of at least 2 feet can be a good practice for infection control or personal comfort but may not be culturally significant for all patients. Insisting that family members provide most of the patient's personal care may not align with the patient's cultural norms or preferences. Considering a patient's ethnicity as the most important factor in care planning overlooks the individuality of the patient and may lead to stereotyping or assumptions that are not accurate or helpful in providing tailored care.

3. A client comes into the emergency room and asks to see a doctor. He is anxious, visibly upset, and keeps looking behind him to the waiting room. When the nurse asks his chief complaint, he says, 'My roommate is trying to kill me.' Which of the following is the most appropriate initial response of the nurse?

• A. Just wait here and I will notify security.
• B. I'm going to speak with the physician about getting some medication that may help you.
• C. Why is your roommate trying to kill you?
• D. Have you called the police to report this?

Correct answer: C

Rationale: Upon initial assessment of a client who appears anxious and upset, with claims that need further exploration, the nurse's initial response should be to gather more information about the situation. By asking 'Why is your roommate trying to kill you?' the nurse shows empathy while trying to understand the patient's perspective. This open-ended question allows the nurse to assess the situation comprehensively. Options A and D jump to conclusions or suggest actions without understanding the situation. Option B focuses solely on medication without addressing the underlying issue. It is crucial to assess the situation further before taking any action or providing treatment.

4. When assessing an older adult, which vital sign changes would the nurse recognize as occurring with aging?

• A. Increase in pulse rate
• B. Widened pulse pressure
• C. Increase in body temperature
• D. Decrease in diastolic blood pressure

Correct answer: B

Rationale: When assessing an older adult, the nurse should be aware that with aging, systolic blood pressure tends to increase, resulting in widened pulse pressure. While in many older individuals both systolic and diastolic pressures increase, the pulse rate and body temperature typically do not increase with aging. Therefore, the correct answer is widened pulse pressure. Choices A, C, and D are incorrect because pulse rate does not necessarily increase with age, body temperature generally remains stable, and diastolic blood pressure may increase instead of decreasing in many older adults.

5. Which action by a client who requires an above-the-knee amputation for peripheral arterial disease best indicates emotional readiness for the surgery?

• A. Explains the goals of the procedure
• B. Displays few signs of anticipatory grief
• C. Participates in learning perioperative care
• D. Verbalizes acceptance of permanent dependency needs

Correct answer: C

Rationale: Participating actively in learning self-care demonstrates emotional acceptance of the need for surgery and readiness for planning post-surgery. Explaining the goals of the procedure may reflect intellectual readiness but not necessarily emotional readiness. A client who shows few signs of anticipatory grief may be suppressing emotions or in denial, which can hinder the emotional readiness. Verbalizing acceptance of permanent dependency needs suggests the client may require further education and emotional support, as it may not reflect a healthy emotional readiness for the surgery.

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