Nursing Elites

1. A client is post-op day #1 after a hemilaminectomy. The nurse removes the dressing as ordered and notes that the incision appears slightly red, with a small amount of serous drainage coming from the site. The edges of the incision are approximated. What is the next action of the nurse?

• A. Assist the client to shower as ordered and monitor the site for further changes
• B. Instruct the client to lie prone to allow the site to dry
• C. Place antibiotic ointment and a sterile dressing over the site
• D. Notify the physician for an antibiotic order

Correct answer: A

Rationale: An incision that appears slightly red with a small amount of serous drainage on the first day following surgery is going through a normal healing process. It is important to keep the incision clean. In this case, the nurse should assist the client to shower as ordered to maintain hygiene and monitor for changes in the incision site. Instructing the client to lie prone may not be necessary and could cause discomfort. Applying antibiotic ointment without a specific order is not recommended as it can interfere with the healing process. Notifying the physician for an antibiotic order is premature at this stage since the incision is showing normal signs of healing.

2. Which of the following scenarios provides an example of a healthcare professional overcoming a barrier to communication?

• A. A healthcare professional uses a visual aid to explain how to conduct a fingerstick glucose test to a patient with visual impairment.
• B. A healthcare professional writes down instructions for a patient who is hearing impaired.
• C. A healthcare professional raises their voice when speaking to a patient who does not speak English.
• D. A healthcare professional uses medical jargon while conversing with a minor.

Correct answer: B

Rationale: Overcoming barriers to communication in healthcare involves utilizing methods of communication that are accessible and understandable to the recipient. In the scenario provided, writing down instructions for a patient who is hearing impaired is an effective way to ensure clear communication and overcome the obstacle of hearing impairment. This method allows the patient to visually comprehend the information provided. Choice A is incorrect because using a visual aid for a visually impaired patient, not a hearing-impaired patient, would be more appropriate. Choice C is incorrect as raising one's voice does not address the language barrier effectively and may not enhance understanding. Choice D is incorrect as using complex medical terms with a minor may lead to confusion and hinder effective communication.

3. What is the first aid for frostbite?

• A. Running cold water over the affected area. Warm or hot water will shock the area and cause more tissue damage.
• B. Run warm water over the area to rapidly rewarm the affected area.
• C. Run hot water over the area to warm the area as quickly as possible.
• D. Cover the area with a blanket, using a heating pad if the blanket isn't warm enough.

Correct answer: A

Rationale: First aid for frostbite involves running cold water over the affected area. It is important to avoid warm or hot water as it can shock the area and cause further tissue damage. Warm water should not be used to rapidly rewarm the affected area. Similarly, hot water should also be avoided as it can warm the area too quickly and potentially cause harm. Covering the area with a blanket and using a heating pad may not be effective and can even lead to more damage. Seeking medical assistance is crucial if the tissue appears necrotic to prevent further complications.

4. The client often sighs and says in a monotone voice, 'I'm never going to get over this.' When encouraged to participate in care, the client says, 'I don't have the energy.' These cues are suggestive of which nursing diagnoses? Select all that apply.

• A. Hopelessness
• B. Power
• C. Interrupted sleep pattern
• D. Disturbed self-esteem

Correct answer: A

Rationale: A nursing diagnosis involves clinical judgment about a response to a health problem. In this scenario, the client's expressions of feeling overwhelmed and lacking energy indicate feelings of hopelessness and powerlessness. While fatigue is mentioned, there is no direct evidence to support an interrupted sleep pattern, making option C incorrect. Similarly, disturbed self-esteem and self-care deficit are not evident from the given cues, making options D and E incorrect.

5. You are taking care of 5 patients today. One of your patients wants water; another needs help walking to the bathroom; another just stated that they have chest pain; and another is crying because his daughter did not visit him today. Which patient care problem must you deal with first?

• A. The water
• B. Help to the bathroom
• C. The chest pain
• D. The crying person

Correct answer: C

Rationale: The chest pain must be addressed immediately as it could indicate a serious condition like a heart attack. Treating chest pain is a top priority in healthcare settings due to the potential life-threatening nature of the symptom. Providing immediate attention to chest pain ensures prompt assessment, diagnosis, and intervention, which are crucial for patient safety and well-being. Addressing the other needs, such as providing water, assisting with bathroom needs, or emotional support, can follow once the urgent issue of chest pain has been managed. While the other patient concerns are important, the critical nature of chest pain requires immediate action to rule out severe cardiac events and provide appropriate care.

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