Nursing Elites

1. In the Emergency Department, a female client discloses that she was raped last night. Which question is most important for the nurse to ask?

• A. Does she know the person who raped her?
• B. Has she taken a bath since the rape occurred?
• C. Is the place where she lives a safe place?
• D. Did she report the rape to the police department?

Correct answer: A

Rationale: The most important question for the nurse to ask in this situation is whether the client knows the person who raped her. This question is crucial for assessing additional safety concerns, providing appropriate support, and determining the need for forensic evidence collection. Choices B, C, and D are not as critical in the immediate assessment and response to a rape victim. Asking about bathing, the safety of her home, or reporting to the police may be important but are secondary to identifying the perpetrator for safety and legal reasons.

2. A client diagnosed with a deep vein thrombus (DVT) followed by a diagnosis of pulmonary embolism (PE) is receiving heparin via an infusion pump at a rate of 1400 u/hour. The client tells the nurse, “I wish this medicine would hurry up and dissolve this clot in my lung so that I can go home”. What response is best for the nurse to provide?

• A. Heparin prevents further clot formation, but your risk of bleeding needs to be monitored closely
• B. You seem to be concerned about the length of time it takes for Heparin to dissolve this clot
• C. Let me contact your healthcare provider to discuss the possibility of receiving IV heparin therapy at home
• D. Why are you so anxious to leave the hospital when you know you are not well enough yet?

Correct answer: A

Rationale: The correct response is A: 'Heparin prevents further clot formation, but your risk of bleeding needs to be monitored closely.' Heparin is an anticoagulant that prevents further clot formation, but it does not quickly dissolve existing clots. It is crucial for the nurse to educate the client about the purpose of heparin and the necessity for close monitoring of bleeding risks. Choice B is incorrect as it does not address the misunderstanding about heparin's mechanism of action. Choice C is incorrect as home administration of IV heparin therapy requires careful consideration and should not be suggested without a thorough assessment. Choice D is incorrect as it does not address the client's misconception about heparin's role in dissolving clots and instead focuses on the client's desire to leave the hospital.

3. A newly hired unlicensed assistive personnel (UAP) is assigned to a home healthcare team along with two experienced UAPs. Which intervention should the home health nurse implement to ensure adequate care for all clients?

• A. Ask the most experienced UAP on the team to partner with the newly hired UAP.
• B. Evaluate the newly hired UAP’s level of competency by observing the UAP deliver care.
• C. Review the UAP’s skills checklist and experience with the person who hired the UAP.
• D. Assign the newly hired UAP to clients who require the least complex level of care.

Correct answer: B

Rationale: Evaluating the newly hired UAP’s competency by observing them deliver care is the most effective intervention to ensure they can provide safe and effective care. This approach directly assesses the UAP's actual performance and allows for immediate feedback. Option A, asking the most experienced UAP to partner with the newly hired one, may not guarantee that the new UAP is competent. Option C, reviewing the UAP’s skills checklist and experience with the hiring person, does not provide a direct assessment of the UAP's current abilities. Option D, assigning the new UAP to less complex cases, does not address the need to evaluate their competency directly.

4. An older male was recently admitted to the rehabilitation unit with unilateral neglect syndrome as a result of a cerebrovascular accident (CVA). Which action should the nurse include in the plan of care?

• A. Provide additional light in the room to promote sensory stimulation
• B. Teach the client to turn his head from side to side for visual scanning
• C. Place a clock and calendar in the room to improve orientation
• D. Use hand and arm gestures to improve communication and comprehension

Correct answer: B

Rationale: Teaching the client to turn his head from side to side for visual scanning is essential in addressing unilateral neglect syndrome caused by a cerebrovascular accident. This action helps improve visual awareness and assists the client in overcoming the neglect of one side of the body. Providing additional light for sensory stimulation (Choice A) may not directly address the issue of unilateral neglect. Placing a clock and calendar in the room (Choice C) may be helpful for orientation but does not specifically target unilateral neglect. Using hand and arm gestures for communication (Choice D) may aid in communication but does not directly address the visual scanning deficits associated with unilateral neglect syndrome.

5. What is the primary focus of postoperative nursing care for the client with colon trauma?

• A. Monitoring for elevated coagulation studies
• B. Observation for and prevention of fistulas
• C. Monitoring for signs of hyponatremia
• D. Observation for and prevention of infection

Correct answer: D

Rationale: The correct answer is D: Observation for and prevention of infection. Postoperative nursing care for a client with colon trauma primarily focuses on preventing infections. Clients with colon trauma are at high risk for infections due to the disruption of the intestinal barrier. Monitoring for signs of infection, maintaining proper wound care, administering antibiotics as prescribed, and implementing strict aseptic techniques are essential in preventing postoperative infections. Choices A, B, and C are incorrect because elevated coagulation studies, fistulas, and hyponatremia are not the primary concerns in the immediate postoperative period for a client with colon trauma.

Similar Questions