Nursing Elites

1. A client is scheduled for a bronchoscopy. After the nurse explains the procedure, which statement by the client indicates a need for further teaching?

• A. I'm glad I don’t have to lie still for this procedure.
• B. I will have a local anesthetic to help with discomfort.
• C. I hope I get some medicine to relax me.
• D. I can't eat or drink for 6 hours before the procedure.

Correct answer: A

Rationale: The correct answer is A because the client's statement indicates a misunderstanding about the need to lie still during the bronchoscopy procedure. The client actually needs to remain still for the procedure to ensure its accuracy and safety. Choices B, C, and D demonstrate an understanding of the procedure by acknowledging the local anesthetic for discomfort, the possibility of receiving medicine for relaxation, and the requirement to fast before the procedure, respectively.

2. A client has a terminal diagnosis and their health is declining. The client requests information about advance directives. Which of the following responses should the nurse make?

• A. Offering to discuss advance directives and provide brochures respects the client's request and provides information.
• B. Informing the client that advance directives are not necessary at this time is incorrect as they play a crucial role in end-of-life care.
• C. Scheduling a meeting with the family to discuss advance directives is not the most appropriate response as the client directly requested information.
• D. Directing the client to ask their provider about advance directives does not directly address the client's request for information.

Correct answer: A

Rationale: When a client with a terminal illness asks about advance directives, it is essential to provide the information they seek. Choice A is the correct response as it acknowledges the client's request and offers to discuss advance directives while providing additional resources in the form of brochures. This approach empowers the client to make informed decisions about their end-of-life care. Choices B, C, and D are incorrect because they do not directly address the client's request or provide the information the client is seeking. Choice B dismisses the importance of advance directives, which are crucial in end-of-life care planning. Choice C involves the family unnecessarily when the client directly requested information. Choice D deflects the responsibility back to the client to seek information from their provider instead of addressing their immediate request.

3. The healthcare provider is planning care for a 14-year-old client returning from scoliosis corrective surgery. Which of the following actions should receive priority in the plan?

• A. Administer antibiotic therapy for 10 days
• B. Teach the client isometric exercises for legs
• C. Assess movement and sensation of extremities
• D. Assist the client to stand up at the bedside within the first 24 hours

Correct answer: C

Rationale: Assessing movement and sensation of extremities is the priority after scoliosis corrective surgery as it helps in early detection of any neurological deficits that may have occurred during the procedure. This assessment is essential for prompt intervention if any issues are identified. Administering antibiotics, teaching exercises, and assisting the client to stand up are important aspects of care but assessing neurological status takes precedence to ensure the client's safety and recovery.

4. A client has an order for 1000 ml of D5W over an 8-hour period. The nurse discovers that 800 ml has been infused after 4 hours. What is the priority nursing action?

• A. Ask the client if there are any breathing problems
• B. Have the client void as much as possible
• C. Check the vital signs
• D. Auscultate the lungs

Correct answer: D

Rationale: The correct answer is D: Auscultate the lungs. When a significant amount of fluid has been infused, especially in a short period, it is crucial to assess for signs of fluid overload or pulmonary complications, such as crackles or decreased breath sounds. This can be achieved by auscultating the lungs. Choice A, asking the client about breathing problems, may provide valuable information, but direct assessment through auscultation takes priority. Choice B, having the client void, and Choice C, checking vital signs, are important nursing actions but are not as urgent as assessing the lungs for potential complications in this scenario.

5. The healthcare provider attaches a pulse oximeter to a client's fingers and obtains an oxygen saturation reading of 91%. Which assessment finding most likely contributes to this reading?

• A. BP 142/88 mmHg
• B. 2+ edema of fingers and hands
• C. Radial pulse volume is +3
• D. Capillary refill time is 2 seconds

Correct answer: B

Rationale: Edema, indicated by 2+ edema of fingers and hands, can impair blood flow and peripheral perfusion, leading to reduced oxygen saturation readings on a pulse oximeter. High blood pressure (choice A) would not directly affect oxygen saturation readings. Radial pulse volume (choice C) and capillary refill time (choice D) are more related to assessing circulation rather than contributing significantly to oxygen saturation readings.

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