Nursing Elites

1. When a nurse assigned to a manipulative client for 5 days becomes aware of feelings of reluctance to interact with the client, what should be the next action by the nurse?

• A. Discuss the feeling of reluctance with an objective peer or supervisor
• B. Limit contact with the client to avoid reinforcement of the manipulative behavior
• C. Confront the client about the negative effects of behaviors on other clients and staff
• D. Develop a behavior modification plan that will promote more functional behavior

Correct answer: A

Rationale: The correct action for the nurse in this situation is to discuss the feeling of reluctance with an objective peer or supervisor. By doing so, the nurse can address their emotions professionally and seek guidance on how to manage the situation effectively. This approach allows the nurse to receive support and potentially gain insights on how to navigate interactions with the manipulative client. Option B is incorrect because avoiding the client may not address the underlying issues causing the reluctance and can impact the quality of care provided. Option C is inappropriate as confronting the client directly about negative behaviors may escalate the situation and harm the therapeutic relationship. Option D is not the immediate action needed in this scenario; it is essential to address the nurse's feelings first before considering behavior modification plans.

2. A patient is placed in the Sims' position. Which areas will the nurse observe for pressure points?

• A. Chin, elbow, hips
• B. Ileum, clavicle, humerus
• C. Shoulder, anterior iliac spine, ankles
• D. Occipital region of the head, coccyx, heels

Correct answer: B

Rationale: When a patient is placed in the Sims' position, the nurse should observe pressure points on the ileum, clavicle, humerus, knees, and ankles. Choice A is incorrect as the chin and hips are not typically pressure points in the Sims' position. Choice C is incorrect as the shoulder and anterior iliac spine are not commonly observed pressure points in this position. Choice D is also incorrect as the occipital region of the head, coccyx, and heels are not pressure points commonly associated with the Sims' position.

3. The LPN/LVN is assisting with the care of a client who has just had a liver biopsy. What position should the nurse place the client in immediately following the procedure?

• A. Supine with the right arm raised above the head
• B. Supine with the head of the bed elevated
• C. Right side-lying with a pillow under the costal margin
• D. Left side-lying with the head of the bed flat

Correct answer: C

Rationale: The correct position for a client immediately following a liver biopsy is right side-lying with a pillow under the costal margin. This position helps prevent bleeding by applying pressure to the biopsy site. Placing the client supine with the right arm raised above the head (Choice A) or supine with the head of the bed elevated (Choice B) are not ideal positions for post-liver biopsy care as they do not provide the necessary pressure to the biopsy site. Left side-lying with the head of the bed flat (Choice D) is also not recommended as it does not assist in preventing bleeding after a liver biopsy.

4. A client has an indwelling urinary catheter. Which of the following assessment findings indicates that the catheter requires irrigation?

• A. Bladder scan shows 525 mL of urine
• B. Urine has a strong odor
• C. The client reports abdominal discomfort
• D. The catheter is blocked or not draining

Correct answer: D

Rationale: The correct answer is D because if the catheter is blocked or not draining, it may need irrigation to restore proper flow. Option A, 'Bladder scan shows 525 mL of urine,' does not necessarily indicate the need for irrigation as it could be within the expected range for catheter drainage. Option B, 'Urine has a strong odor,' may indicate a urinary tract infection but does not directly correlate with the need for catheter irrigation. Option C, 'The client reports abdominal discomfort,' could indicate various issues but does not specifically suggest the need for catheter irrigation.

5. A client is reporting difficulty falling asleep. Which of the following measures should the nurse recommend?

• A. Drink a cup of hot cocoa before bedtime
• B. Exercise 1 hour before going to bed
• C. Use progressive relaxation techniques at bedtime
• D. Reflect on the day's activities before going to bed

Correct answer: C

Rationale: The correct answer is to recommend the client to use progressive relaxation techniques at bedtime. Progressive relaxation techniques help reduce stress and muscle tension, which can promote better sleep. Choice A, drinking a cup of hot cocoa before bedtime, contains caffeine which can interfere with falling asleep. Choice B, exercising 1 hour before going to bed, can stimulate the body and mind, making it harder to fall asleep. Choice D, reflecting on the day's activities before going to bed, may lead to increased mental activity and prevent relaxation, making it difficult to fall asleep.

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