Nursing Elites

1. A client with a history of coronary artery disease is experiencing chest pain. What is the priority action for the nurse to take?

• A. Administer oxygen via a nasal cannula.
• B. Measure the client's vital signs.
• C. Obtain a 12-lead ECG.
• D. Encourage the client to use pursed-lip breathing.

Correct answer: A

Rationale: Administering oxygen via a nasal cannula is the priority action for a client experiencing chest pain due to coronary artery disease. Oxygen therapy helps improve oxygenation, reduce myocardial workload, and relieve chest pain by increasing oxygen delivery to the heart muscle. While measuring vital signs, obtaining a 12-lead ECG, and encouraging pursed-lip breathing are important interventions, administering oxygen takes precedence in this situation to address the potential hypoxemia associated with chest pain in a client with a history of coronary artery disease.

2. At the surgical scrub sink, a surgical nurse demonstrated the proper surgical handwashing technique by scrubbing:

• A. With her hands held lower than her elbows
• B. With her hands held higher than her elbows
• C. With her hands in a fist position
• D. With hands placed on her chest

Correct answer: B

Rationale: The correct technique for surgical handwashing involves scrubbing with hands held higher than the elbows. This positioning helps prevent water from the contaminated area (the hands) from flowing towards the cleaner area (the elbows). This directional flow minimizes the risk of contaminating the scrubbed hands during the handwashing process. Choices A, C, and D are incorrect: A - having hands lower than elbows would risk contamination of the clean area, C - using a fist position does not ensure proper coverage and thorough handwashing, and D - placing hands on the chest is not part of the proper surgical handwashing technique.

3. An adolescent client in an outpatient mental health facility tells the nurse that it is hard to follow his treatment plans because his friends discourage him. Which of the following statements should the nurse make?

• A. Ask, 'Tell me more about how your friends discourage you.'
• B. Say, 'Your friends should support you, not discourage you.'
• C. Respond, 'It sounds like your friends are not supportive.'
• D. Suggest, 'You need to focus on your treatment plans regardless of your friends.'

Correct answer: A

Rationale: The correct approach for the nurse is to ask the client to elaborate on how their friends discourage them. By doing so, the nurse shows empathy, encourages the client to express their feelings, and gains insight into the situation. This open-ended question can help the nurse understand the specific issues the client is facing and work towards finding solutions collaboratively. Choices B, C, and D do not effectively address the client's concerns or encourage further discussion. Choice B is directive and may come off as judgmental, choice C assumes the friends are not supportive without exploring further, and choice D dismisses the client's feelings and the impact of peer influence.

4. The patient diagnosed with diabetes is reporting severe foot pain due to corns and has been using oval corn pads to self-treat the corns. Which information will the nurse share with the patient?

• A. Corn pads are an adequate treatment and should be continued.
• B. The patient should avoid soaking the feet before using a pumice stone.
• C. The current self-treatment is likely impeding circulation to the toes.
• D. Tighter shoes would help compress the corns and make them smaller.

Correct answer: C

Rationale: The nurse should inform the patient that using oval corn pads can increase pressure on the toes and impede circulation, which may exacerbate foot problems in patients with diabetes. It is important to avoid practices that restrict blood flow to the feet, as poor circulation can lead to serious complications. Soaking the feet and using a pumice stone can be beneficial for corns, but in this case, the current self-treatment with corn pads is not recommended. Tighter shoes would further increase pressure on the corns and should be avoided. Therefore, the nurse should emphasize the importance of proper foot care and recommend alternative treatments to promote foot health and prevent complications.

5. A community health nurse is caring for a group of families. The nurse should identify which of the following families is experiencing a maturational loss?

• A. A family whose only child recently died due to cancer.
• B. A family whose head of household lost her job.
• C. A family whose house was destroyed in a fire.
• D. A family whose oldest child is moving away for college.

Correct answer: D

Rationale: The correct answer is D because maturational loss is related to developmental changes, such as children leaving for college. This type of loss is tied to the normal life transitions of individuals and can lead to feelings of grief and adjustment. Choices A, B, and C represent different types of losses. Choice A involves a traumatic loss of a child due to illness, choice B involves a financial loss impacting the head of household's job, and choice C involves a material loss due to a fire incident. While these losses are significant, they do not specifically relate to maturational loss, which is associated with expected life stage transitions.

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