Nursing Elites

1. A client has a nursing diagnosis of 'Spiritual distress related to a loss of hope, secondary to impending death.' What intervention is best for the nurse to implement when caring for this client?

• A. Help the client accept the final stage of life.
• B. Assist and support the client in establishing short-term goals.
• C. Encourage the client to make future plans, even if they are unrealistic.
• D. Instruct the client's family to focus on positive aspects of the client's life.

Correct answer: B

Rationale: When a client is experiencing spiritual distress due to a loss of hope related to impending death, it is crucial for the nurse to assist and support the client in establishing short-term goals. This approach helps the client maintain hope and a sense of purpose, as achieving immediate goals can provide a sense of accomplishment and meaning. While acceptance of the final stage of life is important, helping the client set short-term goals is a more immediate and effective intervention in addressing spiritual distress. Encouraging the client to make future plans, especially if they are unrealistic, may not be beneficial as it could lead to further distress if those plans are unattainable. Instructing the client's family to focus on positive aspects of the client's life, though supportive, does not directly address the client's spiritual distress and loss of hope.

2. While the nurse is discharging an adult woman who was hospitalized for 6 days for treatment of pneumonia and reviewing the prescribed medications, the client appears anxious. What action is most important for the nurse to implement?

• A. Instruct the client to repeat the medication plan
• B. Encourage the client to take a PRN antianxiety drug
• C. Provide written instructions that are easy to follow
• D. Include a family member in the teaching session

Correct answer: A

Rationale: In this situation, the most important action for the nurse to implement is to instruct the client to repeat the medication plan. By using the teach-back method, the nurse can ensure the client's understanding of the prescribed medications and address any concerns or anxieties the client may have. This approach promotes patient engagement, active participation, and retention of important information, ultimately enhancing medication adherence and safety.

3. The healthcare provider is assessing several clients prior to surgery. Which factor in a client's history poses the greatest threat for complications to occur during surgery?

• A. Taking birth control pills for the past 2 years
• B. Taking anticoagulants for the past year
• C. Recently completing antibiotic therapy
• D. Having taken laxatives PRN for the last 6 months

Correct answer: B

Rationale: Anticoagulants increase the risk of bleeding during surgery, which can lead to complications such as excessive bleeding and difficulty in achieving hemostasis. This poses a significant threat during a surgical procedure where controlling bleeding is crucial for a successful outcome. The other options (A, C, D) are not as critical as anticoagulants in terms of posing a threat for complications during surgery. Birth control pills, recently completing antibiotic therapy, and using laxatives do not directly impact bleeding risks during surgery compared to anticoagulants.

4. The caregiver learns the use of a gait belt from the nurse for a woman with right-sided weakness. The caregiver demonstrates the skill. Which observation indicates that the caregiver has learned how to perform this procedure correctly?

• A. Standing on the woman's strong side, the caregiver is ready to hold the gait belt if any evidence of weakness is observed.
• B. Standing on the woman's weak side, the caregiver provides security by holding the gait belt from the back.
• C. Standing behind the woman, the caregiver provides balance by holding both sides of the gait belt.
• D. Standing slightly in front and to the right of the woman, the caregiver guides her forward by gently pulling on the gait belt.

Correct answer: B

Rationale: The correct answer is B. Standing on the weak side of the client and holding the gait belt from the back provides better security and support during ambulation, reducing the risk of falls. This positioning allows the caregiver to offer stability and assistance without interfering with the client's movement, ensuring safe ambulation for the client with right-sided weakness. Choices A, C, and D are incorrect because they do not provide the optimal support and security needed for a client with right-sided weakness. Standing on the weak side and holding the gait belt from the back is the most effective way to assist the client while minimizing the risk of falls.

5. When assessing a client with wrist restraints, the nurse observes that the fingers on the right hand are blue. What action should the nurse implement first?

• A. Loosen the right wrist restraint.
• B. Apply a pulse oximeter to the right hand.
• C. Compare hand color bilaterally.
• D. Palpate the right radial pulse.

Correct answer: A

Rationale: The priority nursing action is to restore circulation by loosening the restraint (A) because blue fingers (cyanosis) indicate decreased circulation. Comparing hand color bilaterally (C) and palpating the right radial pulse (D) are important assessments to gather more information, but they do not have the priority of addressing the decreased circulation by loosening the restraint. Applying a pulse oximeter (B) is not indicated in this scenario as it measures the saturation of hemoglobin with oxygen, which is not relevant when cyanosis is related to mechanical compression from the restraints.

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