Nursing Elites

1. A client is having an abortion in a women's clinic, and the nurse caring for the client does not think the reasoning is appropriate. The nurse asks, "Are you sure you want to do this? It can't be undone. Have you read about your other options? Adoption is always a good choice."? The client states she understands all options and is comfortable with her choice. The nurse nods and leaves the room to discuss the procedure with the physician. Which client right did the nurse violate with her actions?

• A. the client's right to make personal health decisions without interference, as the nurse tried to sway the client's decision-making and healthcare choice in the direction of not having an abortion
• B. the client's right to be left alone without unsolicited attention, as the nurse inserted herself in the client's healthcare scenario and offered uninvited advice
• C. the client's right to confidentiality, as the nurse is talking to the physician about the client and the abortion
• D. the client's right to respectful care, as the nurse clearly made it known that she did not approve of the abortion

Correct answer: A

Rationale: A client has the right to make decisions about their healthcare without interference from healthcare team members. In this scenario, the nurse violated the client's right to make personal health decisions without interference by trying to influence the client's decision-making and healthcare choice in the direction of not having an abortion. It is essential for healthcare providers to respect patients' autonomy and decisions, regardless of personal beliefs. Choices B, C, and D are incorrect because the primary violation in this situation is related to the client's right to make their own healthcare decisions without interference.

2. While undergoing fetal heart monitoring, a pregnant Native-American woman requests that a medicine woman be present in the examination room. Which of the following is an appropriate response by the nurse?

• A. "I will assist you in arranging to have a medicine woman present."?
• B. "We do not allow medicine women in exam rooms."?
• C. "That does not make any difference in the outcome."?
• D. "It is old-fashioned to believe in that."?

Correct answer: A

Rationale: The correct response is to show cultural awareness and acceptance by offering to assist in arranging for the medicine woman to be present. This demonstrates respect for the client's beliefs and preferences. Choice B is inappropriate as it dismisses the client's request without considering its cultural significance. Choice C is dismissive and does not acknowledge the client's values. Choice D is disrespectful and judgmental, undermining the client's beliefs. Therefore, the only appropriate and professional response is to support the client's request and offer assistance in accommodating it.

3. An 80-year-old aphasic CVA client had abdominal surgery 2 days ago. Which of the following puts this client at the highest risk for inadequate pain management?

• A. Inability to turn, cough, and breathe deeply
• B. Inability to communicate pain
• C. Inability to ambulate freely
• D. Inability to use a bedside commode

Correct answer: B

Rationale: The correct answer is B: Inability to communicate pain. In this scenario, the client's aphasia prevents them from verbally expressing their pain, which can lead to inadequate pain management if the healthcare team is not vigilant. The nurse must use alternative methods to assess and address the client's pain. Choices A, C, and D, although important considerations in postoperative care, do not directly relate to the client's ability to communicate pain, which is crucial for effective pain management in this case.

4. What should a client room environment include?

• A. a made bed, fresh water, thermostat regulation, and clean floors in all occupied client areas.
• B. a made bed, comfort and safety, a clutter-free area, hygiene articles nearby.
• C. accident prevention, comfort, a room (including furniture) that has been cleaned with chloroseptic wash, a bed that is made every other day.
• D. odor control (by spraying the room with deodorizers), closet storage of all client objects, a clean room. (Gloves should be worn when cleaning.)

Correct answer: B

Rationale: A client room environment should include a made bed to provide a sense of neatness and comfort, ensuring the client's safety at all times. It is important to maintain a clutter-free area to prevent accidents and promote a relaxing environment. Having hygiene articles nearby allows the client easy access to personal care items. Choice A is incorrect because while fresh water and thermostat regulation are important, they are not essential components of a client room environment. Choice C is incorrect as it emphasizes more on cleaning procedures rather than creating a comfortable and safe environment for the client. Choice D is incorrect as it emphasizes odor control and storage rather than the client's comfort and safety.

5. A nurse is preparing for the admission of a client with pulmonary tuberculosis. Which action reflects the use of evidence-based practice in the care of the client?

• A. Keeping the door to the client's room closed
• B. Fitting the client for an N95 or HEPA (high-efficiency particulate air) mask to be worn at all times
• C. Placing the client in a semiprivate room with a cohort client
• D. Using a surgical mask when entering the client's room

Correct answer: A

Rationale: Evidence-based practice is an approach to client care that integrates the client's preferences, clinical expertise, and the best research evidence to deliver quality care. In the case of pulmonary tuberculosis, which is transmitted through the airborne route, keeping the door to the client's room closed is crucial to prevent the spread of infection. Placing the client in a semiprivate room with a cohort client is not recommended for airborne precautions; a private room is required to prevent transmission. Fitting the client for an N95 or HEPA mask is essential for the nurse's protection when entering the room, not for the client to wear at all times. Using a surgical mask when entering the client's room is not sufficient for airborne precautions; an N95 or HEPA mask is necessary.

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