Nursing Elites

1. While obtaining a lie-sit-stand blood pressure reading on a client, what action is most important for the nurse to implement?

• A. Stay with the client while the client is standing.
• B. Record the findings on the graphic sheet in the chart.
• C. Keep the blood pressure cuff on the same arm.
• D. Record changes in the client's pulse rate.

Correct answer: A

Rationale: The most crucial action for the nurse to implement when obtaining a lie-sit-stand blood pressure reading is to stay with the client while the client is standing. This is essential to monitor the client's immediate response to position changes and ensure their safety. Recording the findings on the graphic sheet is important for documentation but is not as critical as staying with the client. Keeping the blood pressure cuff on the same arm helps maintain consistency in readings but is not as vital as ensuring client safety. Recording changes in the client's pulse rate is important for a comprehensive assessment but does not take precedence over monitoring the client during position changes.

2. While receiving a preoperative enema, a client starts to cry and says, 'I'm sorry you have to do this messy thing for me.' Which is the nurse's best response?

• A. I don't mind it.'
• B. 'You seem upset.'
• C. 'This is part of my job.'
• D. 'Nurses get used to this.'

Correct answer: B

Rationale: The nurse's best response in this situation is to acknowledge the client's emotional state, as it shows empathy and encourages further expression of feelings. Choice A, 'I don't mind it,' dismisses the client's emotions and does not address the underlying issue. Choice C, 'This is part of my job,' focuses on the task rather than the client's emotional needs. Choice D, 'Nurses get used to this,' minimizes the client's feelings and lacks empathy. By selecting choice B, 'You seem upset,' the nurse acknowledges the client's distress and opens the door for further communication and support.

3. Based on the nursing diagnosis of risk for infection, which intervention is best for the nurse to implement when providing care for an older incontinent client?

• A. Maintain standard precautions.
• B. Initiate contact isolation measures.
• C. Insert an indwelling urinary catheter.
• D. Instruct the client in the use of adult diapers.

Correct answer: A

Rationale: The correct intervention for a nursing diagnosis of risk for infection in an older incontinent client is to maintain standard precautions. The best way to reduce the risk of infection in vulnerable clients is through proper handwashing and adherence to standard precautions. Option B, initiating contact isolation measures, is excessive unless the client has a confirmed infection requiring isolation. Option C, inserting an indwelling urinary catheter, actually increases the risk of infection due to the introduction of a foreign body. Option D, instructing the client in the use of adult diapers, does not directly address the risk of infection and is not as effective as maintaining standard precautions in preventing infection transmission.

4. Which basic principle of Alcoholics Anonymous (AA) should a client with alcohol use disorder follow?

• A. Spouses should attend Al-Anon meetings.
• B. It is a commitment to focus on long-term goals.
• C. Amends must be made to each person who has been harmed.
• D. People have the power to overcome alcoholism if they truly want to stop drinking.

Correct answer: C

Rationale: The correct answer is that amends must be made to each person who has been harmed. This principle is reflected in the eighth step of the 12 steps of AA, which involves making a list of all persons harmed and being willing to make amends to them. It is a fundamental principle of AA to address past harms and seek to rectify them. Choice A is incorrect because spouses attending Al-Anon meetings is not a basic principle of AA; it is a support group for family members of individuals with alcohol use disorder. Choice B is incorrect because while focusing on long-term goals can be beneficial, AA emphasizes taking one day at a time rather than committing to long-term goals. Choice D is incorrect because AA teaches that individuals struggling with alcoholism are powerless over their addiction and need to rely on a higher power rather than solely their willpower to overcome it.

5. Which component of cultural competence is being demonstrated when the nurse motivates the immigrant to accept differences in the way a pregnant woman is cared for in her current residence?

• A. Cultural desire
• B. Cultural awareness
• C. Cultural knowledge
• D. Cultural encounters

Correct answer: A

Rationale: The correct answer is 'Cultural desire.' Cultural desire involves the nurse's motivation and commitment toward caring for individuals from diverse backgrounds. In this scenario, motivating the immigrant to accept differences in prenatal care reflects the nurse's genuine interest in providing culturally competent care. Cultural awareness involves self-examination of one's beliefs and biases. Cultural knowledge refers to understanding various cultural practices and beliefs. Cultural encounters focus on interactions across cultures to enhance communication and mutual understanding. Therefore, in this context, the nurse's actions align more closely with the concept of cultural desire.

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