Nursing Elites

1. The nurse teaches a patient about the transmission of pulmonary tuberculosis (TB). Which statement, if made by the patient, indicates that teaching was effective?

• A. I will avoid being outdoors whenever possible.
• B. My husband will be sleeping in the guest bedroom.
• C. I will take the bus instead of driving to visit my friends.
• D. I will keep the windows closed at home to contain the germs.

Correct answer: B

Rationale: To prevent the transmission of pulmonary tuberculosis, it is important for the infected individual to minimize exposure to close contacts and household members. Sleeping alone in a separate room, like the guest bedroom, is an effective measure. The other choices are not ideal: Choice A is incorrect because spending time outdoors is encouraged for ventilation; Choice C is incorrect as using public transportation increases the risk of transmission; Choice D is incorrect because keeping windows closed limits ventilation, which is necessary to reduce the concentration of infectious particles in the air.

2. If you are caring for a patient of the Hindu culture, what may you anticipate regarding visitors?

• A. Limited visitors, respectful of privacy
• B. Family members only
• C. Large number of visitors/community support
• D. None of the above

Correct answer: C

Rationale: In Hindu culture, there is a strong sense of community and support. It is common for a patient to receive a large number of visitors, indicative of the community coming together to provide emotional and practical support. This support network is crucial for the patient's well-being and healing process. Option A, limited visitors, is incorrect as the Hindu culture values community involvement. Option B, family members only, is incorrect as the support network extends beyond just family. Option D, none of the above, is incorrect as the Hindu culture typically involves community support and a significant number of visitors.

3. You are attempting to teach the wife of a Greek patient how to administer his gastrostomy tube feedings once he returns home. She smiles and nods through your explanations, but when you ask her for a return demonstration, she looks confused and shakes her head. Her daughter enters the room and states that she does not speak English. What would be most helpful in this situation?

• A. Teach the daughter instead
• B. Teach both and ask the daughter to translate for you
• C. Contact a home health agency to provide care
• D. Provide a pamphlet with detailed instructions

Correct answer: B

Rationale: Teaching both the patient's wife and the daughter is the best option in this situation. The daughter may not always be available, and the wife is eager to care for her husband at home. While a hospital interpreter is often preferred, asking the daughter to interpret is a good alternative. This approach allows the daughter to receive instruction and reinforce it for herself as she translates it to her mother. Contacting a home health agency may not be necessary if family members are willing and able to assist. Providing a pamphlet with detailed instructions would not be as effective in ensuring the wife fully understands the procedure and can carry it out correctly.

4. A nurse is using active listening as a form of therapeutic communication when:

• A. She uses humor to put the client at ease in a situation
• B. She restates what the client said in slightly different words
• C. She uses eye contact and maintains an open stance while the client is talking
• D. She provides personal information to show the client she can relate to him

Correct answer: C

Rationale: Active listening is a form of therapeutic communication that involves the nurse encouraging a client to express their thoughts and feelings. Maintaining eye contact and an open stance while the client is talking demonstrates active listening and shows the client that they are being heard and understood. Using humor (Choice A) may not always be appropriate or therapeutic in all situations. Restating what the client said (Choice B) is a technique known as paraphrasing and is also a form of active listening. Providing personal information (Choice D) can shift the focus from the client to the nurse, which is not the intention of active listening.

5. A nurse is caring for a client who is post-op day #1 after a total hip replacement. Although the client was alert with a normal affect in the morning, by lunchtime, the nurse notes the client is confused, has slurred speech, and is having trouble with her balance. Her blood glucose level is 48 mg/dl. What is the next action of the nurse?

• A. Contact the physician immediately
• B. Administer a bolus of 50 cc of D20W through the IV
• C. Administer 10 units of regular insulin
• D. Give the client 6 oz. of orange juice

Correct answer: D

Rationale: A client with a blood glucose level of 48 mg/dl is experiencing significant hypoglycemia, as manifested by confusion, balance difficulties, and slurred speech. The nurse should work to correct this situation as rapidly as possible. The first measure that can be performed quickly and will have fast results is to give the client something to eat or drink that contains glucose, such as 6 oz. of orange juice. Administering a bolus of D20W through the IV (Choice B) would be too aggressive and could lead to complications in this scenario. Administering regular insulin (Choice C) would further lower the blood glucose level, worsening the client's symptoms. Contacting the physician (Choice A) is important, but immediate intervention to raise the blood glucose level is crucial to address the client's hypoglycemia.

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