Nursing Elites

1. When a male Korean-American client looks away when asked by the nurse to describe his problem, what is the best initial nursing action?

• A. Ask for assistance from social services to find a Korean interpreter.
• B. Establish indirect eye contact with the client.
• C. Allow several minutes for the client to respond.
• D. Repeat the question using simpler language.

Correct answer: C

Rationale: In this scenario, the best initial nursing action is to allow several minutes for the client to respond. This approach respects the cultural norms of the client, as in some cultures, direct eye contact may be perceived as disrespectful or intrusive. By giving the client time to gather his thoughts and respond at his own pace, the nurse promotes effective communication and demonstrates cultural sensitivity. Asking for assistance from social services to find a Korean interpreter (Choice A) may be necessary for further communication but is not the best initial action. Establishing indirect eye contact (Choice B) may still make the client uncomfortable. Repeating the question using simpler language (Choice D) may not address the underlying cultural aspect affecting the client's response.

2. The nurse determines that a client's pupils constrict as they change focus from a far object. What documentation should the nurse enter about this finding?

• A. Pupils reactive to accommodation.
• B. Nystagmus present with pupillary focus.
• C. Peripheral vision intact.
• D. Consensual pupillary constriction present.

Correct answer: A

Rationale: The correct answer is A: 'Pupils reactive to accommodation.' When pupils constrict as the client changes focus from a far object to a near one, it indicates a normal response known as accommodation. This physiological process allows the eyes to adjust their focus, and it is a healthy finding. Choice B is incorrect because nystagmus is an involuntary eye movement, not related to the change in focus. Choice C is irrelevant to the scenario and does not describe the observed finding. Choice D refers to pupillary constriction in response to light, not accommodation to changes in focus.

3. While taking vital signs, a critically ill male client grabs the nurse's hand and asks the nurse not to leave. What action is best for the nurse to take?

• A. Pull up a chair and sit beside the client's bed.
• B. Reassure the client that you will return shortly.
• C. Ask another nurse to stay with the client.
• D. Continue taking vital signs and then leave the room.

Correct answer: A

Rationale: The best action for the nurse to take in this situation is to pull up a chair and sit beside the client's bed. By doing so, the nurse can provide emotional support and comfort to the critically ill patient who is feeling vulnerable. Sitting with the client also shows empathy and a willingness to listen to the client's needs. Reassuring the client that the nurse will return shortly (Choice B) may not address the immediate need for emotional support. Asking another nurse to stay with the client (Choice C) may not establish the same level of connection and comfort as sitting with the client personally. Continuing to take vital signs and then leaving the room (Choice D) disregards the client's emotional needs in that moment.

4. A client with cirrhosis is admitted with jaundice and ascites. Which intervention should the nurse implement first?

• A. Administer a diuretic as prescribed.
• B. Administer lactulose as prescribed.
• C. Monitor the client's weight daily.
• D. Assess the client's neurological status.

Correct answer: B

Rationale: Administering lactulose is the first priority in managing a client with cirrhosis to reduce ammonia levels and prevent worsening hepatic encephalopathy. Lactulose helps in decreasing the absorption of ammonia in the intestines and promotes its excretion through the stool. This intervention is crucial in preventing the development or progression of hepatic encephalopathy. Administering a diuretic (Choice A) may be necessary to manage ascites, but it is not the priority over lactulose in this scenario. Monitoring the client's weight (Choice C) is important to assess fluid retention but is not the first intervention required. Assessing the client's neurological status (Choice D) is essential in cirrhosis, but administering lactulose takes precedence to prevent hepatic encephalopathy.

5. A female client reports that she drank a liter of a solution to cleanse her intestines but vomited immediately after. How many ml of fluid intake should the nurse document?

• A. 1000 ml
• B. 800 ml
• C. 760 ml
• D. 500 ml

Correct answer: C

Rationale: The correct answer is 760 ml. One liter equals 1000 ml. As the client vomited immediately after drinking, she would have expelled approximately 240 ml (1 cup). Subtracting this from the initial intake of 1000 ml gives us 760 ml as the remaining fluid intake that should be documented. Choices A, B, and D are incorrect because they do not reflect the correct calculation of subtracting the amount vomited from the initial intake.

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