Nursing Elites

1. A healthcare professional is caring for a client who has a prescription for a stool specimen to be sent to the laboratory to be tested for ova and parasites. Which of the following instructions regarding specimen collection should the healthcare professional provide to the assistive personnel?

• A. Collect at least 2 inches of formed stool.
• B. Wear sterile gloves while obtaining the specimen.
• C. Use a culturette for specimen collection.
• D. Record the date and time the stool was collected.

Correct answer: A

Rationale: To ensure accurate testing, a minimum amount of stool is required for specimen collection, typically at least 2 inches of formed stool. This amount provides an adequate sample for testing. Wearing sterile gloves is important for infection control but is not specifically required for stool specimen collection. Using a culturette is not typically necessary for collecting stool specimens. Recording the date and time the stool was collected is essential to ensure timely processing but does not directly impact the collection of the specimen itself.

2. A client has a terminal diagnosis and their health is declining. The client requests information about advance directives. Which of the following responses should the nurse make?

• A. Offering to discuss advance directives and provide brochures respects the client's request and provides information.
• B. Informing the client that advance directives are not necessary at this time is incorrect as they play a crucial role in end-of-life care.
• C. Scheduling a meeting with the family to discuss advance directives is not the most appropriate response as the client directly requested information.
• D. Directing the client to ask their provider about advance directives does not directly address the client's request for information.

Correct answer: A

Rationale: When a client with a terminal illness asks about advance directives, it is essential to provide the information they seek. Choice A is the correct response as it acknowledges the client's request and offers to discuss advance directives while providing additional resources in the form of brochures. This approach empowers the client to make informed decisions about their end-of-life care. Choices B, C, and D are incorrect because they do not directly address the client's request or provide the information the client is seeking. Choice B dismisses the importance of advance directives, which are crucial in end-of-life care planning. Choice C involves the family unnecessarily when the client directly requested information. Choice D deflects the responsibility back to the client to seek information from their provider instead of addressing their immediate request.

3. In planning care for a premature infant with respiratory distress syndrome, nursing actions are based on the fact that the most likely cause of this problem stems from the infant's inability to

• A. Stabilize alveolar surface tension
• B. Maintain alveolar surface tension
• C. Promote normal pulmonary blood flow
• D. Regulate intra-cardiac pressure

Correct answer: B

Rationale: The correct answer is B: Maintain alveolar surface tension. Respiratory distress syndrome in premature infants is often caused by a deficiency in surfactant, a substance that helps maintain alveolar surface tension. Without adequate surfactant, the alveoli collapse, making it difficult for the infant to oxygenate effectively. Choices A, C, and D are incorrect because stabilizing alveolar surface tension is not the issue, promoting normal pulmonary blood flow and regulating intra-cardiac pressure are not directly related to the pathophysiology of respiratory distress syndrome in premature infants.

4. A client is admitted with a diagnosis of Guillain-Barre syndrome. Which assessment finding is most concerning?

• A. Loss of reflexes in the legs
• B. Decreased peripheral sensation
• C. Respiratory distress
• D. Muscle weakness in the arms

Correct answer: C

Rationale: The correct answer is C: Respiratory distress. In Guillain-Barre syndrome, respiratory distress is the most concerning finding as it can indicate progression to respiratory failure, which is a life-threatening complication. Loss of reflexes in the legs and muscle weakness in the arms are common manifestations of the condition but may not be as immediately life-threatening as respiratory distress. Decreased peripheral sensation is also a common symptom but is not as critical as respiratory distress in terms of immediate patient safety and management.

5. A male client presents to the clinic stating that he has a high-stress job and is having difficulty falling asleep at night. The client reports having a constant headache and is seeking medication to help with sleep. Which intervention should the nurse implement?

• A. Determine the client's sleep and activity pattern
• B. Obtain a prescription for the client to take when stressed
• C. Refer the client for a sleep study and neurological follow-up
• D. Teach coping strategies to use when feeling stressed

Correct answer: A

Rationale: The correct intervention for the nurse to implement in this scenario is to determine the client's sleep and activity pattern. By assessing the client's patterns, the nurse can identify factors contributing to the sleep issues and tailor appropriate interventions. Choice B is incorrect because prescribing medication without a comprehensive assessment is not the initial step. Choice C is unnecessary at this stage as the client's symptoms are likely related to stress rather than a neurological disorder. Choice D, while important, should come after understanding the client's sleep patterns to provide holistic care. Therefore, option A is the best choice to address the client's sleep difficulties and headaches effectively.

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