Nursing Elites

1. A nurse is admitting a client who has schizophrenia and experiences auditory hallucinations. The client states, 'It's hard not to listen to the voices.' Which of the following questions should the nurse ask?

• A. Do you understand that the voices are not real?
• B. Why do you think the voices are talking to you?
• C. Have you tried going to a private place when this occurs?
• D. What helps you ignore what you are hearing?

Correct answer: D

Rationale: The correct answer is 'D: What helps you ignore what you are hearing?' Asking the client about coping mechanisms is essential in assisting them to manage auditory hallucinations. Choice A is incorrect as questioning the reality of the voices may not be helpful. Choice B delves into the cause of the hallucinations rather than coping strategies. Choice C focuses on isolation rather than addressing the client's coping mechanisms.

2. A nurse is caring for a client who has a prescription for a low-sodium diet. Which of the following foods should the nurse recommend?

• A. Pickles
• B. Fresh vegetables
• C. Canned soup
• D. Smoked salmon

Correct answer: B

Rationale: Fresh vegetables are an excellent choice for clients on a low-sodium diet as they are naturally low in sodium. Pickles, canned soup, and smoked salmon are high in sodium and should be avoided by clients following a low-sodium diet. Pickles are pickled in a brine solution high in sodium, canned soup usually contains added salt for preservation, and smoked salmon is a processed food that typically has a high sodium content.

3. What is the most important nursing intervention for a patient with a suspected pulmonary embolism?

• A. Administer anticoagulants
• B. Administer oxygen
• C. Reposition the patient
• D. Monitor oxygen saturation

Correct answer: A

Rationale: The most important nursing intervention for a patient with a suspected pulmonary embolism is to administer anticoagulants. Anticoagulants help prevent further clot formation in the patient's blood vessels, reducing the risk of complications such as worsening of the pulmonary embolism or development of new clots. Administering oxygen (Choice B) may be necessary to support the patient's oxygenation, but anticoagulants take precedence as they target the underlying cause of the pulmonary embolism. Repositioning the patient (Choice C) and monitoring oxygen saturation (Choice D) are important aspects of patient care but are not the primary intervention for a suspected pulmonary embolism.

4. A client is receiving discharge teaching for a new prescription of warfarin. Which statement by the client indicates an understanding of the teaching?

• A. I will need to increase my intake of leafy green vegetables.
• B. I will avoid drinking grapefruit juice while taking warfarin.
• C. I will have my INR checked regularly.
• D. I will take my medication at the same time each day.

Correct answer: C

Rationale: The correct answer is C. Clients on warfarin therapy need to have their International Normalized Ratio (INR) checked regularly to monitor the medication's effectiveness and prevent complications like clotting or bleeding. Option A is incorrect because increasing leafy green vegetables can affect INR levels due to their vitamin K content. Option B is incorrect as grapefruit juice is not a significant concern with warfarin. Option D is important for medication adherence but does not specifically address the monitoring aspect required for warfarin therapy.

5. A nurse is preparing to perform a bladder scan for a client who has overflow incontinence. Which of the following actions should the nurse take?

• A. Place the client in a supine position.
• B. Obtain a prescription for insertion of an indwelling catheter.
• C. Cleanse the client's abdomen with an antiseptic solution.
• D. Prepare the client for urinary catheterization.

Correct answer: D

Rationale: The correct answer is to prepare the client for urinary catheterization. Overflow incontinence may indicate bladder distention, where a bladder scan helps assess the need for catheterization. Placing the client in a supine position (Choice A) is not directly related to the procedure. Obtaining a prescription for an indwelling catheter (Choice B) is not necessary before performing a bladder scan. Cleansing the client's abdomen with an antiseptic solution (Choice C) is not specific to preparing for a bladder scan in this situation.

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