Nursing Elites

1. When a client with schizophrenia who experiences auditory hallucinations says, 'It's hard not to listen to the voices,' which question 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 question for the nurse to ask the client who experiences auditory hallucinations and finds it hard not to listen to the voices is, 'What helps you ignore what you are hearing?' This question focuses on promoting coping strategies and therapeutic communication, encouraging the client to share what techniques or interventions have been effective for managing the auditory hallucinations. Choice A is incorrect because it assumes the client does not understand that the voices are not real, which may not be the case. Choice B delves into the reasons behind the voices, which may not be immediately helpful in managing the current situation. Choice C suggests a physical solution of going to a private place, which may not address the underlying issue of coping with the voices.

2. A nurse is providing teaching to a client who is experiencing preterm contractions and dehydration. Which statement should the nurse make?

• A. Dehydration is treated with calcium supplements.
• B. Dehydration can increase the risk of preterm labor.
• C. Dehydration is caused by decreased hemoglobin and hematocrit.
• D. Dehydration causes gastroesophageal reflux.

Correct answer: B

Rationale: The correct statement is B: 'Dehydration can increase the risk of preterm labor.' Dehydration can lead to increased uterine irritability, potentially causing preterm contractions and labor. Choice A is incorrect as dehydration is not treated with calcium supplements but rather with fluids. Choice C is incorrect as dehydration is not caused by decreased hemoglobin and hematocrit levels but rather by a lack of fluids. Choice D is incorrect as dehydration does not directly cause gastroesophageal reflux.

3. A patient is receiving radiation therapy. Which of the following skin care instructions should the nurse provide?

• A. Apply a heating pad to the radiation site.
• B. Use scented lotions to moisturize the skin.
• C. Keep the radiation site covered with a bandage.
• D. Wear loose clothing over the radiation site.

Correct answer: D

Rationale: Correct Answer: The nurse should instruct the patient to wear loose clothing over the radiation site. This helps prevent skin irritation and promotes healing by reducing friction and irritation on the treated area.\nChoice A is incorrect because applying a heating pad can further irritate the skin that is already sensitive due to radiation therapy.\nChoice B is incorrect because scented lotions may contain ingredients that could further irritate the skin.\nChoice C is incorrect because covering the radiation site with a bandage can trap moisture and lead to skin breakdown, increasing the risk of infection.

4. What is the primary action when a healthcare provider discovers a patient has fallen?

• A. Assess the patient for injuries
• B. Call for help immediately
• C. Document the fall
• D. Notify the healthcare provider

Correct answer: A

Rationale: When a healthcare provider discovers a patient has fallen, the primary action should be to assess the patient for injuries. This is crucial to determine the extent of harm and if immediate treatment is necessary. Calling for help is important, but assessing the patient's condition takes precedence to ensure the patient's safety and well-being. While documenting the fall and notifying the healthcare provider are essential steps, they come after assessing the patient's injuries.

5. A nurse is assessing a client who is 48 hours postoperative following a hip replacement. Which of the following findings should the nurse report to the provider?

• A. Heart rate 90/min.
• B. WBC count 15,000/mm3.
• C. Urinary output 75 mL in the past 4 hours.
• D. Temperature 37.8°C (100°F).

Correct answer: B

Rationale: An elevated WBC count 48 hours postoperatively may indicate an infection and should be reported to the provider. Choice A, a heart rate of 90/min, is within normal limits and not a concerning finding postoperatively. Choice C, urinary output of 75 mL in the past 4 hours, may indicate decreased renal perfusion, but an elevated WBC count is a more urgent finding. Choice D, a temperature of 37.8°C (100°F), which is slightly elevated, could be indicative of the body's normal response to surgery and is not as alarming as an elevated WBC count.

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