Nursing Elites

1. A female client’s significant other has been at her bedside providing reassurances and support for the past 3 days, as desired by the client. The client’s estranged husband arrives and demands that the significant other not be allowed to visit or be given condition updates. Which intervention should the nurse implement?

• A. Obtain a prescription from the healthcare provider regarding visitation privileges
• B. Request a consultation with the ethics committee for resolution of the situation
• C. Encourage the client to speak with her husband regarding his disruptive behavior
• D. Communicate the client’s wishes to all members of the multidisciplinary team

Correct answer: B

Rationale: In a situation where a client's estranged husband demands to restrict the visitation of the significant other, it is essential to prioritize the client's wishes while addressing the conflict. Requesting a consultation with the ethics committee is appropriate as it allows for a comprehensive and impartial resolution, ensuring the client's autonomy and well-being are upheld. Option A is incorrect because visitation privileges are not solely determined by a healthcare provider's prescription in this scenario. Option C may not be appropriate as it puts the client in a potentially uncomfortable or unsafe position. Option D, while important, does not directly address the conflict between the estranged husband and the significant other.

2. At 0100 on a male client’s second postoperative night, the client states he is unable to sleep and plans to read until feeling sleepy. What action should the nurse implement?

• A. Leave the room and close the door to the client’s room
• B. Assess the appearance of the client’s surgical dressing
• C. Bring the client a prescribed PRN sedative-hypnotic
• D. Discuss symptoms of sleep deprivation with the client

Correct answer: A

Rationale: The client has expressed a plan to read until feeling sleepy, indicating that he is managing his inability to sleep. In this situation, it is best for the nurse to respect the client's autonomy and leave the room, providing privacy and an opportunity for the client to relax and hopefully fall asleep. Closing the door can also help create a quiet environment conducive to rest.

3. The patient had a CVA and developed right-sided hemiplegia. Which action is least appropriate for the nurse to take?

• A. Performing ROM exercises during bathing.
• B. Changing the patient's position every two hours.
• C. Suctioning the patient supine and tightly pulling the bed sheets across their feet.
• D. Placing the patient in the prone position for one hour three times a day.

Correct answer: C

Rationale: Suctioning the patient in a supine position and pulling the bed sheets tightly across their feet can lead to foot drop, which is harmful for a patient with right-sided hemiplegia. This action can exacerbate muscle weakness and impair circulation in the affected limb. It is crucial to avoid actions that may compromise the patient's safety and well-being, such as causing foot drop in this scenario.

4. When culturing a wound, the nurse should obtain the sample from which part of the wound?

• A. The outer edges of the wound.
• B. All necrotic sections of the wound.
• C. Areas containing purulent or pooled exudates.
• D. Any particularly painful area of the wound.

Correct answer: C

Rationale: To collect a wound culture, the nurse should first clean the wound to remove skin flora and then insert a sterile swab from a culturette tube into the wound secretions.

5. A client with a diagnosis of chronic obstructive pulmonary disease (COPD) is receiving oxygen via nasal cannula at 4 liters per minute. Which assessment finding indicates a need for immediate action?

• A. The client's respiratory rate is 14 breaths per minute.
• B. The client's oxygen saturation is 92%.
• C. The client reports shortness of breath.
• D. The client's respiratory rate is 24 breaths per minute.

Correct answer: C

Rationale: A report of shortness of breath (C) indicates that the client is not tolerating the oxygen therapy well and may need an adjustment. Shortness of breath is a critical symptom in a client with COPD, as it signifies potential respiratory distress. A respiratory rate of 14 (A) is within an acceptable range for a client with COPD and does not require immediate action. An oxygen saturation of 92% (B) is slightly lower but still acceptable in COPD patients. Although a respiratory rate of 24 (D) is higher, it is not as immediately concerning as shortness of breath in this context.

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