Nursing Elites

1. After a client has a tubal ligation in the outpatient surgical clinic, what is the priority for the nurse to determine?

• A. The client's prior experiences with outpatient surgery
• B. The client's medical plan and the extent of coverage for outpatient surgery
• C. The client's plan for transportation and care at home
• D. The client's plan to spend the night at the surgical center

Correct answer: C

Rationale: The priority for the nurse is to ensure the client has a safe way to get home and adequate care after discharge. It is crucial to determine the client's transportation arrangements and availability of care at home to ensure a smooth transition postoperatively. Options A and B, though important, are not immediate priorities compared to the client's safety and well-being after the procedure. Option D is incorrect as spending the night at the surgical center is not typically part of the plan for outpatient surgery.

2. While making rounds at 3 am, the nurse discovers a small fire in a client's room. What should the nurse do first?

• A. Remove the client from the room immediately.
• B. Leave the client's room to obtain a fire extinguisher.
• C. Instruct a nurse tech to pull the fire alarm.
• D. Evacuate all clients from the unit.

Correct answer: A

Rationale: During a fire emergency, the priority is the safety of the individual in the room where the fire is located. Removing the client from the room immediately is the first step in the RACE acronym for fire safety: Rescue/Remove, Alarm, Contain, and Extinguish. This action ensures the client's safety before addressing the fire itself. Choice B is incorrect as leaving the client's room to obtain a fire extinguisher can delay the immediate removal of the client from the danger. Choice C is incorrect as pulling the fire alarm should be done after ensuring the client's safety. Choice D is incorrect as evacuating all clients from the unit should come after ensuring the safety of the individual in immediate danger.

3. Which of the following goals is the most important for the nurse to address for a client admitted to the cardiac rehabilitation unit?

• A. Reduction of anxiety
• B. Referral to community resources
• C. Identification of lifestyle changes
• D. Verbalization of energy-conservation techniques

Correct answer: C

Rationale: The most important goal for a client admitted to the cardiac rehabilitation unit is the identification of lifestyle changes. This is crucial in promoting cardiovascular health and preventing future cardiac issues. Lifestyle changes such as diet modifications, exercise routines, smoking cessation, and stress management play a significant role in improving the overall cardiovascular well-being of the patient. While reducing anxiety, referring to community resources, and verbalizing energy-conservation techniques are all important aspects of care, identifying lifestyle changes is the primary focus in helping the client achieve long-term cardiovascular wellness.

4. Chemotherapeutic agents often produce a degree of myelosuppression including leukopenia. Leukopenia does not present immediately but is delayed several days or weeks because:

• A. the client's hemoglobin and hematocrit are normal.
• B. red blood cells are affected first.
• C. folic acid levels are normal.
• D. the current white cell count is not affected by chemotherapy.

Correct answer: D

Rationale: Leukopenia does not present immediately after chemotherapy because time is required to clear circulating cells before the effect on precursor cell maturation in the bone marrow becomes evident. Leukopenia is characterized by an abnormally low white blood cell count. The correct answer is D because the white cell count is not immediately affected by chemotherapy. Choices A, B, and C are incorrect as they pertain to red blood cells (hemoglobin and hematocrit), which are not directly related to the delayed onset of leukopenia.

5. The client is undergoing an induction for fetal demise at 34 weeks. Immediately after delivery, the mother asks to see the infant. What is the nurse's best response?

• A. Bring the swaddled fetus to the mother
• B. Explain that the cause of death must be determined before she can see the baby
• C. Ask her if she is sure she wants to see the baby
• D. Tell her it would be better to wait until she is in her room before she sees the baby

Correct answer: A

Rationale: The nurse should bring the swaddled fetus to the mother as the best response. Allowing the mother to see the infant immediately after delivery is crucial for her grieving process. It provides her with the opportunity to bond, say goodbye, and start the grieving process. Choice B is incorrect because delaying the mother's request to see the baby can hinder her grieving process and prolong her suffering. Choice C is inappropriate as it questions the mother's decision at a sensitive time, potentially causing distress. Choice D is also not the best response as it suggests waiting, which may not be in the mother's best interest at that moment, as she needs immediate support and closure.

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