Nursing Elites

1. A female client with deteriorating neurologic function states, "I am worried I will not be able to care for my young children."? How does the nurse respond?

• A. "Caring for your children is a priority. You may not want to ask for help, but you have to."?
• B. "Our community has resources that may help you with some household tasks so you have energy to care for your children."?
• C. "You seem distressed. Would you like to talk to a psychologist about adjusting to your changing status?"?
• D. "Give me more information about what worries you, so we can see if we can do something to make adjustments."?

Correct answer: D

Rationale: When a client expresses worry about not being able to care for her children due to deteriorating neurologic function, the most appropriate response from the nurse is to gather more information from the client. This open-ended approach allows the nurse to better understand the client's specific concerns and needs, leading to tailored interventions and support. Choice A is dismissive and may make the client feel guilty for needing help. Choice B focuses on external resources without addressing the client's worries directly. Choice C suggests a psychological referral without exploring the client's concerns further. Therefore, the correct response is to gather more information to provide personalized support.

2. The nurse assesses distended neck veins in a client sitting in a chair to eat. What intervention is the nurse's priority?

• A. Document the observation in the chart.
• B. Measure urine specific gravity and volume.
• C. Assess the pulse and blood pressure.
• D. Assess the client's deep tendon reflexes.

Correct answer: C

Rationale: The correct answer is to assess the pulse and blood pressure. Distended neck veins can indicate fluid volume overload or heart failure, which can lead to hemodynamic instability. Assessing the pulse and blood pressure will provide immediate information on the client's cardiovascular status. Documenting the observation in the chart (choice A) is important but not the priority when immediate assessment is needed. Measuring urine specific gravity and volume (choice B) is important for assessing renal function but is not the priority in this situation. Assessing the client's deep tendon reflexes (choice D) is not relevant to addressing distended neck veins in a client sitting to eat.

3. The healthcare provider is assessing a client before surgery. Which assessments contraindicate the client from having surgery as scheduled? (Select one that does not apply.)

• A. Potassium level of 2.8 mEq/L
• B. International normalized ratio (INR) of 4
• C. Prothrombin time (PT) of 30 seconds
• D. Positive pregnancy test

Correct answer: C

Rationale: The correct answer is C: Prothrombin time (PT) of 30 seconds. A low potassium level (choice A) and an elevated INR (choice B) indicate potential bleeding risks during surgery. A positive pregnancy test (choice D) in a female client can lead to complications during surgery. However, a Prothrombin time of 30 seconds is within the normal range and does not contraindicate the client from having surgery as scheduled.

4. What intervention is most important to teach the client about identifying the onset of dehydration?

• A. Measuring abdominal girth
• B. Converting ounces to milliliters
• C. Obtaining and charting daily weight
• D. Selecting food items with high water content

Correct answer: C

Rationale: The correct answer is C: Obtaining and charting daily weight. Monitoring daily weight is crucial in identifying the onset of dehydration as weight loss can be an early sign. Measuring abdominal girth (choice A) is not the most reliable method for detecting dehydration. Converting ounces to milliliters (choice B) and selecting food items with high water content (choice D) may be important for overall hydration but are not the most critical interventions for identifying the onset of dehydration.

5. A client is diagnosed with varicella (chickenpox). The nurse places the client on which precautions?

• A. Airborne
• B. Standard
• C. Contact
• D. Droplet

Correct answer: A

Rationale: The correct answer is 'Airborne.' Varicella (chickenpox) is caused by the varicella-zoster virus, which spreads through the air by respiratory droplets. Therefore, placing the client on airborne precautions is necessary to prevent the transmission of the virus. Choice B, 'Standard precautions,' involve basic infection prevention measures that are used for all client care. Choice C, 'Contact precautions,' are used for diseases that spread by direct or indirect contact. Choice D, 'Droplet precautions,' are implemented for diseases transmitted by respiratory droplets that are larger than 5 microns.

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