Nursing Elites

1. A client who has recently started using a behind-the-ear hearing aid is being cared for by a nurse. Which of the following statements should the nurse identify as an indication that the client understands the use of assistive devices?

• A. “I will be sure to remove my hearing aid before taking a shower.”
• B. “I will keep my hearing aid in at all times, even when sleeping.”
• C. “I will clean my hearing aid with alcohol.”
• D. “I will turn off my hearing aid when not in use.”

Correct answer: A

Rationale: The correct answer is A. It is crucial for the client to remove the hearing aid before showering to prevent damage from moisture. Choice B is incorrect as wearing the hearing aid all the time, including during sleep, is not recommended and can cause discomfort or harm. Choice C is incorrect as alcohol can damage hearing aids; they should be cleaned with a solution recommended by the manufacturer to prevent harm. Choice D is incorrect because hearing aids should not be turned off when not in use; instead, they should be stored properly following the manufacturer's instructions to maintain functionality and battery life.

2. Postoperatively, signs of hemorrhagic shock are observed. The nurse notifies the surgeon, who instructs to continue monitoring vitals every 15 minutes and report back in one hour. What should the nurse do next?

• A. Notify the nurse manager
• B. Continue monitoring as instructed
• C. Administer IV fluids as per protocol
• D. Prepare for immediate transfer to the ICU

Correct answer: B

Rationale: The correct answer is to continue monitoring the patient as instructed. This is crucial to assess the patient's condition and response to initial interventions. Administering IV fluids or preparing for transfer to the ICU should only be done based on further assessment or explicit orders from the healthcare provider. Notifying the nurse manager, as suggested in choice A, without further assessment or intervention could delay immediate patient care and management.

3. A client is scheduled for a total laryngectomy. Which of the following interventions is the priority for the nurse?

• A. Schedule a support session for the client.
• B. Explain the techniques of esophageal speech.
• C. Review the use of artificial larynx with the client.
• D. Determine the client's reading ability.

Correct answer: B

Rationale: The priority intervention for a client scheduled for a total laryngectomy is to explain the techniques of esophageal speech. This is crucial for the client's post-surgery communication. Option A, scheduling a support session, is important but not the priority as ensuring the client can communicate effectively comes first. Option C, reviewing the use of artificial larynx, is relevant but not the priority compared to teaching esophageal speech. Option D, determining the client's reading ability, is not as critical as ensuring the client learns a primary method of communication following the laryngectomy.

4. When admitting an older adult client who is Hispanic, which of the following cultural considerations should the nurse include when developing the plan of care?

• A. The Hispanic culture views late adulthood as a time of wisdom and experience
• B. The Hispanic culture expects adult children to care for older adult parents
• C. The Hispanic culture identifies the eldest female family member as the decision maker
• D. The Hispanic culture expects individuals to make their own decisions when death is imminent

Correct answer: B

Rationale: In Hispanic culture, there is an expectation that adult children will care for their older parents, emphasizing a strong family support system. This cultural value highlights the importance of filial piety and respect for elders within the family structure. Choice A is incorrect because Hispanic culture generally values late adulthood as a time of wisdom and experience, not a negative time. Choice C is incorrect as Hispanic culture typically involves collective family decision-making rather than assigning decision-making solely to the eldest female member. Choice D is incorrect as Hispanic culture values family support and involvement in end-of-life decisions rather than individual decision-making.

5. A client with moderate persistent asthma is admitted for a minor surgical procedure. On admission, the peak flow meter is measured at 480 liters/minute. Post-operatively, the client is complaining of chest tightness. The peak flow has dropped to 200 liters/minute. What should the nurse do first?

• A. Notify the healthcare provider
• B. Administer the PRN dose of Albuterol
• C. Apply oxygen at 2 liters per nasal cannula
• D. Repeat the peak flow reading in 30 minutes

Correct answer: B

Rationale: In a client with moderate persistent asthma experiencing a drop in peak flow and chest tightness post-operatively, the first action the nurse should take is to administer the PRN dose of Albuterol. Albuterol is a short-acting bronchodilator that helps relieve bronchospasm and improve breathing. Notifying the healthcare provider (choice A) can be done after initiating immediate treatment with Albuterol. Applying oxygen (choice C) may be necessary but addressing the bronchospasm with Albuterol is the priority. Repeating the peak flow reading (choice D) can be considered after administering Albuterol to assess the response to treatment.

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