Nursing Elites

1. A client with schizophrenia is experiencing delusions. Which of the following interventions should the nurse implement?

• A. Tell the client that their delusions are not real
• B. Encourage the client to explore the meaning behind their delusions
• C. Focus on the client's feelings rather than the delusions
• D. Challenge the client's delusions directly

Correct answer: C

Rationale: In caring for a client with schizophrenia experiencing delusions, it is essential to focus on the client's feelings rather than directly addressing or challenging the delusions. By focusing on the client's emotions, the nurse can build trust and rapport without reinforcing the delusions. Choice A is incorrect because directly telling the client that their delusions are not real may lead to confrontation or mistrust. Choice B is incorrect as encouraging exploration of the delusions may further validate them. Choice D is incorrect because challenging the client's delusions can escalate the situation and damage the therapeutic relationship.

2. A nurse is assessing a client who is 1 day postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?

• A. Blood pressure of 110/70 mm Hg
• B. Heart rate of 88/min
• C. Respiratory rate of 20/min
• D. Temperature of 37.3°C (99.1°F)

Correct answer: D

Rationale: The correct answer is D because a temperature of 37.3°C (99.1°F) is slightly elevated, indicating a possible infection or inflammatory response, which should be reported to the provider for further evaluation. Choices A, B, and C are within normal limits for a client postoperative, so they do not require immediate reporting. Elevated temperature can be a sign of infection or other complications, making it a priority for reporting and further assessment.

3. A healthcare professional is assessing a client who is 24 hours postoperative following an open cholecystectomy. Which of the following findings should the healthcare professional report to the provider?

• A. Urinary output of 100 mL in 4 hours
• B. Serosanguineous wound drainage
• C. Heart rate of 94/min
• D. WBC count of 15,000/mm³

Correct answer: D

Rationale: A WBC count of 15,000/mm³ is elevated and may indicate infection, which should be reported. High WBC count is a sign of inflammation or infection, and in a postoperative client, it can be indicative of surgical site infection or another complication. Urinary output, serosanguineous wound drainage, and a heart rate of 94/min are all within normal ranges for a client post cholecystectomy and do not raise immediate concerns for infection or complications.

4. How should a healthcare professional monitor for infection in a patient with a central line?

• A. Check the central line dressing daily
• B. Monitor for signs of redness
• C. Check for abnormal breath sounds
• D. Monitor temperature

Correct answer: A

Rationale: Correct answer: A. Checking the central line dressing daily is crucial to monitor for signs of infection around the insertion site. This practice helps in early detection of any changes such as redness, swelling, or discharge, which are indicators of a potential infection. Monitoring for signs of redness (choice B) is limited as redness alone may not always indicate an infection; other symptoms like discharge and tenderness should also be observed. Checking for abnormal breath sounds (choice C) is not directly related to monitoring central line infections. Monitoring temperature (choice D) is important for detecting systemic signs of infection but may not specifically indicate an infection related to the central line site.

5. What is the most appropriate intervention for a patient with confusion post-surgery?

• A. Administer oxygen
• B. Reposition the patient
• C. Administer IV fluids
• D. Perform a neurological assessment

Correct answer: A

Rationale: Administering oxygen is the most appropriate intervention for a patient with confusion post-surgery because it helps alleviate confusion caused by potential hypoxia. In a post-surgical setting, confusion can be a sign of decreased oxygen levels in the blood due to various reasons such as respiratory depression, decreased lung function, or other complications. Administering oxygen can quickly address hypoxia, improving oxygenation to the brain and reducing confusion. Repositioning the patient, administering IV fluids, or performing a neurological assessment are not the primary interventions for confusion related to hypoxia post-surgery.

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