Nursing Elites

1. During preoperative teaching, a client in a surgeon’s office expresses intent to prepare advance directives before surgery. Which statement by the client indicates understanding of advance directives?

• A. “I’d prefer my brother to make decisions, but I understand it must be my wife.”
• B. “I understand the surgery won’t proceed unless I fill out these forms.”
• C. “I plan to specify my wish to avoid being kept on a breathing machine.”
• D. “I will have my primary doctor review my plan before submitting it at the hospital.”

Correct answer: C

Rationale: The correct answer is C. This statement reflects the client's understanding of advance directives, as it indicates a specific preference regarding life-sustaining treatment. Advance directives enable individuals to outline their healthcare preferences, including decisions about treatments they wish to receive or avoid. Choice A mentions family members but doesn't address specific healthcare wishes; choice B focuses on the surgery rather than personal directives; choice D discusses doctor approval but lacks details about the directive itself.

2. A client with chronic obstructive pulmonary disease (COPD) is being discharged with home oxygen therapy. Which statement by the client indicates a need for further teaching?

• A. I will keep my oxygen tank upright at all times.
• B. I will not use petroleum jelly to keep my nose from drying out.
• C. I will not smoke or allow others to smoke around me.
• D. I will call my doctor if I have difficulty breathing.

Correct answer: B

Rationale: The correct answer is B. Petroleum jelly is flammable and should not be used with oxygen therapy due to the risk of fire. The client should avoid using petroleum-based products around oxygen equipment. Choices A, C, and D are all appropriate statements for a client with COPD receiving home oxygen therapy. Keeping the oxygen tank upright ensures proper oxygen flow, avoiding smoking or exposure to smoke helps prevent respiratory aggravation, and knowing to seek medical help promptly for breathing difficulties is essential for managing COPD effectively.

3. A nurse in an outpatient surgical center is admitting a client for a laparoscopic procedure. The client has a prescription for preoperative diazepam. Prior to administering the medication, which of the following actions is the nurse’s priority?

• A. Teaching the client about the purpose of the medication
• B. Giving the medication at the administration time the provider prescribed
• C. Identifying the client’s medication allergies
• D. Documenting the client’s anxiety level

Correct answer: C

Rationale: The correct answer is C: Identifying the client's medication allergies. This is the priority action before administering any medication to prevent allergic reactions or adverse effects. Teaching the client about the medication's purpose is important for client understanding but not as critical as ensuring the absence of allergies. While giving medication at the prescribed time is crucial, verifying allergies takes precedence to ensure patient safety. Documenting the client's anxiety level is relevant for holistic care but is not the priority compared to ensuring safe medication administration.

4. A client with a chest tube following thoracic surgery needs care. Which task should the nurse delegate to an assistive personnel?

• A. Teach deep breathing and coughing to the client.
• B. Assist the client to select food choices from the menu.
• C. Evaluate the client’s response to pain medication.
• D. Monitor the characteristics of the client's chest tube drainage.

Correct answer: B

Rationale: The correct answer is B because assisting the client with food choices is a task that can be safely delegated to assistive personnel. This task does not require nursing judgment or specialized skills. Choices A, C, and D involve assessing the client's condition, response to treatment, and monitoring critical aspects of care, which are nursing responsibilities that necessitate specialized knowledge and judgment. Teaching deep breathing and coughing (A), evaluating pain medication response (C), and monitoring chest tube drainage (D) require a higher level of training and expertise that should be performed by the nurse.

5. A client with heart failure is being taught by a nurse on reducing daily sodium intake. Which factor is most crucial in determining the client’s ability to learn new dietary habits?

• A. The client's involvement in planning the change
• B. The cost of the dietary changes
• C. The availability of low-sodium foods
• D. The client’s previous dietary knowledge

Correct answer: D

Rationale: The client’s previous dietary knowledge is the most critical factor in determining the ability to learn new dietary habits. Understanding the client's existing dietary knowledge helps tailor the teaching to build upon what they already know. While client involvement in planning changes can increase adherence and motivation, the foundational knowledge is essential for effective learning. The cost of dietary changes and the availability of low-sodium foods are important considerations but not as crucial as the client's existing knowledge.

Similar Questions