Nursing Elites

1. A client diagnosed with a terminal illness asks the nurse about the nurse’s religious beliefs related to death and dying. An appropriate nursing response is to:

• A. Share personal beliefs
• B. Encourage the client to express their thoughts about death and dying
• C. Redirect the conversation to medical treatment
• D. Inform the client that the nurse’s beliefs are not relevant

Correct answer: B

Rationale: Encouraging the client to express their own thoughts about death and dying is an appropriate nursing response in this situation. It allows the client to explore and express their feelings, fears, and beliefs, facilitating a therapeutic conversation. Sharing personal beliefs (choice A) may not be appropriate as it could impose the nurse's beliefs on the client and hinder open discussion. Redirecting the conversation to medical treatment (choice C) may avoid addressing the client's emotional and spiritual needs. Informing the client that the nurse’s beliefs are not relevant (choice D) dismisses the client's concerns and does not encourage open communication.

2. The healthcare professional is evaluating the body alignment of a patient in the sitting position. Which observation will indicate a normal finding?

• A. The edge of the seat is making contact with the popliteal space.
• B. Both feet are supported on the floor with ankles flexed.
• C. The body weight is solely on the buttocks.
• D. The arms hang comfortably at the sides.

Correct answer: B

Rationale: In a normal sitting position, both feet should be supported on the floor with the ankles comfortably flexed. This position helps in maintaining stability and proper alignment. Choice A is incorrect because the edge of the seat pressing against the popliteal space may cause discomfort and is not indicative of proper alignment. Choice C is incorrect as the body weight should be evenly distributed for proper alignment and comfort, not solely on the buttocks. Choice D is incorrect as the position of the arms alone does not indicate proper body alignment in the sitting position; proper arm positioning is important for comfort but not a key indicator of body alignment.

3. A healthcare professional is planning to obtain the vital signs of a 2-year-old child who is experiencing diarrhea and who might have a right ear infection. Which of the following routes should the healthcare professional use to obtain the temperature?

• A. Temporal
• B. Oral
• C. Rectal
• D. Axillary

Correct answer: C

Rationale: In a 2-year-old child with diarrhea and a possible ear infection, rectal temperature measurement is the most accurate reflection of core body temperature. This method provides the most reliable reading, especially in young children, as it closely reflects the core body temperature. Oral temperature may not be accurate due to the child's recent diarrhea, which can affect oral readings. Axillary temperature may not be as accurate as rectal temperature in this case. Temporal temperature measurement, although non-invasive, may not provide the most accurate core body temperature reading, especially in a child with a potential ear infection.

4. When explaining the procedure for collecting a 24-hour urine specimen for creatinine clearance to an older adult male, what should the nurse do next?

• A. Assess the client for confusion and reteach the procedure
• B. Check the urine for color and texture
• C. Empty the urinal contents into the 24-hour collection container
• D. Discard the contents of the urinal

Correct answer: A

Rationale: The correct next step for the nurse is to assess the client for confusion and reteach the procedure. This is crucial to ensure that the older adult male understands the process correctly, reducing the likelihood of errors in collecting the 24-hour urine specimen for creatinine clearance. Checking the urine for color and texture (Choice B) is not the immediate next step as the focus should be on patient understanding first. Emptying the urinal contents into the 24-hour collection container (Choice C) assumes prior knowledge on the client's part and skips the critical step of ensuring comprehension. Discarding the contents of the urinal (Choice D) is incorrect and wasteful since the urine is necessary for the 24-hour collection process.

5. Postoperative client with fluid volume deficit. Which change indicates successful treatment?

• A. Decrease in heart rate
• B. Increase in blood pressure
• C. Decrease in respiratory rate
• D. Increase in urine output

Correct answer: A

Rationale: A decrease in heart rate can indicate improved fluid balance and successful treatment of fluid volume deficit. When a client is experiencing fluid volume deficit, the heart rate typically increases as a compensatory mechanism to maintain cardiac output. As fluid volume is restored and the deficit is corrected, the heart rate should decrease back towards a normal range. Choices B, C, and D are less likely to be directly related to the successful treatment of fluid volume deficit. An increase in blood pressure may occur as a compensatory response to fluid volume deficit; a decrease in respiratory rate is not a typical indicator of fluid volume deficit correction; and an increase in urine output can be a sign of improved kidney function but may not directly reflect fluid volume status.

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