Nursing Elites

1. A 10-year-old who has terminal brain cancer asks the nurse, 'What will happen to my body when I die?' How should the nurse respond?

• A. The heart will stop beating, and you will stop breathing.
• B. You will go to sleep and not wake up.
• C. Your body will stop functioning, and you will no longer feel pain.
• D. You will feel very tired, and your body will shut down slowly.

Correct answer: C

Rationale: The correct answer is C because it provides a truthful yet sensitive response to the child's question. Saying that the body will stop functioning and that there will be no more pain helps the child understand what to expect without unnecessary details or causing distress. Choice A is too technical and may not be suitable for a child. Choice B might give the impression of a peaceful passing, which may not always be the case. Choice D introduces the concept of feeling tired, which might not be accurate or helpful in this context.

2. The nurse is caring for a comatose client. Which assessment finding provides the greatest indication that the client has an open airway?

• A. The client has asymmetrical chest expansion
• B. Percussion reveals dullness over the lung area
• C. Bilateral breath sounds can be auscultated
• D. The client has been turned q2h

Correct answer: C

Rationale: The correct answer is C: "Bilateral breath sounds can be auscultated." This finding indicates that air is moving adequately in and out of both lungs, confirming an open airway. Options A, B, and D are incorrect. Asymmetrical chest expansion may indicate lung or chest wall abnormalities, percussion revealing dullness over the lung area may suggest consolidation or fluid, and turning the client q2h is a position change intervention to prevent complications, not a direct assessment of airway patency.

3. A young female adult wanders into the Emergency Department. She is disheveled and confused and states, 'My date must have put something in my drink. He took my car, and I think he raped me. I don't exactly remember, but I know he hurt me.' How should the nurse respond?

• A. Did you try to resist or fight back when you felt uncomfortable?
• B. He hurt you? Can you elaborate on what happened?
• C. It is okay to cry, but first, let's address your injuries and the situation.
• D. Yes, I can see. Tell me more about what you remember.

Correct answer: D

Rationale: The correct response is to encourage the patient to share more about what she remembers. This approach helps gather crucial information, supports the patient in a non-judgmental manner, and allows the nurse to provide appropriate care. Choice A has been revised to be more sensitive by asking about resistance when feeling uncomfortable rather than placing blame. Choice B has been adjusted to show empathy and request more details without questioning the patient's account. Choice C, although empathetic, does not address the immediate need to collect information and support the patient.

4. A postpartum client who is bottle feeding develops breast engorgement. What is the best recommendation for the nurse to provide this client?

• A. Take a prescribed analgesic and expose breasts to air
• B. Place warm packs on both breasts
• C. Avoid stimulation of the breasts and wear a tight bra
• D. Express a small amount of breast milk by hand

Correct answer: C

Rationale: For a postpartum client who is bottle feeding and develops breast engorgement, the best recommendation is to avoid stimulation of the breasts and wear a tight bra. This helps reduce engorgement by decreasing blood flow to the breasts. Option A is incorrect because exposing the breasts to air can further stimulate them, worsening engorgement. Option B is incorrect as warm packs can increase blood flow and exacerbate engorgement. Option D is incorrect as expressing breast milk can lead to further stimulation and increased engorgement.

5. A continuous infusion of nitroglycerin is prescribed for an adult male admitted with an acute myocardial infarction. The client is experiencing active chest pain that he describes as 8 out of 10. Which intervention is most important for the nurse to implement?

• A. Administer the infusion via an infusion pump
• B. Obtain the current serum potassium level
• C. Continuously monitor blood pressure
• D. Teach guided imagery to decrease pain

Correct answer: C

Rationale: Continuously monitoring blood pressure is crucial in this case because nitroglycerin can cause hypotension as a side effect. Monitoring blood pressure allows the nurse to assess the client's response to the medication and detect any signs of hypotension promptly. This intervention is essential to ensure the effectiveness of nitroglycerin therapy and prevent potential complications. Administering the infusion via an infusion pump is important for accurate dosing but not the most critical at this moment. Obtaining the current serum potassium level is important but not the most immediate concern when the client is experiencing active chest pain. Teaching guided imagery may be beneficial for pain management, but in this scenario, monitoring blood pressure takes precedence due to the potential side effects of nitroglycerin.

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