Nursing Elites

1. Which of the following is an example of restorative care?

• A. A nurse teaches a new mother how to breastfeed her infant
• B. A nurse helps a client with developing a bladder-retraining program
• C. A nurse places an allergy wristband on a client's wrist to notify other providers of potential reactions
• D. A nurse contacts the family of a client to tell them he will be out of surgery soon

Correct answer: B

Rationale: Restorative care involves assisting clients in regaining or maintaining their highest possible level of function. This type of care focuses on promoting self-care and independence by helping clients perform activities that enhance their functional abilities. In this scenario, a nurse who assists a client with developing a bladder-retraining program is engaging in restorative care by helping the client regain bladder function. Choices A, C, and D do not represent restorative care. Teaching a new mother how to breastfeed her infant (Choice A) is an example of educative care, placing an allergy wristband (Choice C) is a safety measure, and contacting a client's family to update them on surgery (Choice D) is related to communication and support, not restorative care.

2. A client with hyperkalemia may exhibit peaked T waves on an electrocardiogram. This manifestation is an early sign of high potassium levels, but the diagnosis should not be based on this aspect alone. Untreated, hyperkalemia can lead to progressively worsening cardiac instability.

• A. A lumbar puncture takes a sample of cerebrospinal fluid from the back, which will be analyzed by the lab.
• B. The physician will insert a needle at the level of L4-L5 in the spinal cord.
• C. The client should lie flat on their back for a specific period following the procedure.
• D. The risks of the procedure include headache, back pain, and infection.

Correct answer: B

Rationale: A lumbar puncture is performed to obtain cerebrospinal fluid for analysis to investigate various conditions affecting the client. During the procedure, the client is typically positioned on their side or sitting leaning over a table with their back rounded. The physician inserts a needle into the back around the L4-L5 vertebrae to collect the sample. Option A is incorrect because a lumbar puncture does not draw blood but instead collects cerebrospinal fluid. Option C is incorrect as the client should not necessarily lie flat for 24 hours post-procedure. Option D is incorrect as the common risks of a lumbar puncture include headache, back pain, and potential infection, not nausea, rash, or hypotension.

3. A nurse is required to float to another unit within the hospital where he is asked to care for a client on a ventilator. The nurse is uncomfortable with this assignment, as he has not had a ventilated client since nursing school. What is the nurse's most appropriate response?

• A. Explain to the nursing supervisor the level of discomfort and ask for a different assignment
• B. State that the client's needs are outside the nurse's scope of practice and request a different assignment
• C. Accept the assignment, asking for help when necessary
• D. Request to return to the home unit and send another nurse who can perform the job

Correct answer: A

Rationale: When floating to another unit and asked to take an assignment that falls outside a nurse's comfort zone, the nurse should notify the area supervisor of the level of discomfort and request a different assignment. Caring for ventilated clients typically falls within the scope of nursing practice; however, discomfort with the situation may not necessarily be overcome by accepting the assignment. Alternatively, the effects could be harmful to the client if the nurse is unfamiliar with this type of care. Requesting a different assignment is the most appropriate response in this situation, ensuring patient safety and the nurse's comfort level. Stating that the client's needs are outside the nurse's scope of practice (Choice B) may not be accurate, as caring for ventilated clients usually falls within the scope of nursing practice. Accepting the assignment (Choice C) without addressing the discomfort may compromise patient safety. Requesting to return to the home unit (Choice D) does not address the immediate need of caring for the ventilated client and may delay appropriate care.

4. Working in a clinic located in a community with many Hispanics, what strategy could the nurse implement to decrease health care disparities for Hispanic patients?

• A. Improve public transportation to the clinic.
• B. Update equipment and supplies at the clinic.
• C. Obtain low-cost medications for clinic patients.
• D. Teach clinic staff about Hispanic health beliefs.

Correct answer: D

Rationale: Health care disparities are primarily rooted in stereotyping, biases, and prejudice among healthcare providers. By educating clinic staff about Hispanic health beliefs, the nurse can help combat these issues, leading to improved cultural competency and patient care. Understanding the cultural context of Hispanic patients can enhance communication, trust, and treatment adherence. Improving public transportation, updating equipment, and obtaining low-cost medications are important aspects of healthcare delivery but do not directly address the underlying causes of health disparities experienced by Hispanic patients.

5. A client in labor has an electronic fetal monitor attached to the abdomen, and the nurse notes that the baby's heart rate slows down during each contraction, returning to normal limits only after the contraction is complete. Which type of fetal heart rate change does this pattern describe?

• A. Variable decelerations
• B. Late decelerations
• C. Early decelerations
• D. Accelerations

Correct answer: B

Rationale: Late decelerations refer to a pattern where the baby's heart rate decreases during contractions and does not return to normal until after the contraction ends. This is considered a non-reassuring sign as it indicates potential fetal distress. Late decelerations are associated with uteroplacental insufficiency, and immediate medical attention is required. Variable decelerations (Choice A) are abrupt, unpredictable decreases in the fetal heart rate, usually associated with cord compression. Early decelerations (Choice C) are usually benign and mirror the contraction pattern. Accelerations (Choice D) are reassuring signs of fetal well-being, characterized by an increase in the fetal heart rate.

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