Nursing Elites

1. A client expresses fear of surgery. Which response should the nurse make?

• A. Explain the risks of the surgery in detail.
• B. Tell the client that many clients feel anxious before surgery.
• C. Reassure the client that the surgical team is highly experienced.
• D. Acknowledge the client's feelings and ask open-ended questions.

Correct answer: D

Rationale: When a client expresses fear of surgery, it is essential for the nurse to acknowledge their feelings and ask open-ended questions. This response shows empathy, validates the client's emotions, and encourages them to express their concerns further. Explaining the risks of the surgery in detail (Choice A) may increase the client's anxiety. Simply stating that many clients feel anxious before surgery (Choice B) does not address the client's specific fears. While reassuring the client about the surgical team's experience (Choice C) is important, it may not directly alleviate the client's fear.

2. A nurse is caring for a client who has bipolar disorder and is experiencing acute mania. The nurse obtained a verbal prescription for restraints. Which of the following actions should the nurse take?

• A. Request a renewal of the prescription every 8 hours.
• B. Check the client's peripheral pulse rate every 30 minutes.
• C. Obtain a prescription for restraint within 4 hours.
• D. Document the client's condition every 15 minutes.

Correct answer: C

Rationale: When caring for a client with bipolar disorder experiencing acute mania and having obtained a verbal prescription for restraints, the nurse must ensure to obtain a formal written prescription for restraint within 4 hours. This is crucial to maintain the safety and proper care of the client. Choices A, B, and D are incorrect because renewing the prescription every 8 hours, checking pulse rate every 30 minutes, and documenting the client's condition every 15 minutes do not address the immediate need for a formal restraint prescription within 4 hours to manage the client's acute mania effectively.

3. A nurse is planning care for a client who has diabetes insipidus and is receiving desmopressin. Which of the following should the nurse monitor?

• A. Fasting blood glucose
• B. Carbohydrate intake
• C. Hematocrit
• D. Weight

Correct answer: D

Rationale: The correct answer is D: Weight. Weight monitoring is essential to assess the effectiveness of desmopressin therapy, as fluid retention is a common side effect. Monitoring fasting blood glucose (choice A) is not directly related to desmopressin therapy for diabetes insipidus. Monitoring carbohydrate intake (choice B) may be important in diabetes management but is not specific to desmopressin therapy. Hematocrit (choice C) monitoring is not a primary concern when managing diabetes insipidus with desmopressin.

4. A healthcare professional is caring for a client who has an arteriovenous fistula. Which of the following findings should the healthcare professional report?

• A. Thrill upon palpation.
• B. Absence of a bruit.
• C. Distended blood vessels.
• D. Swishing sound upon auscultation.

Correct answer: B

Rationale: The correct answer is B: Absence of a bruit. In a client with an arteriovenous fistula, the presence of a bruit (a humming sound) is an expected finding due to the high-pressure flow of blood through the fistula. Therefore, the absence of a bruit suggests a complication, such as thrombosis or stenosis, which should be reported for further evaluation and management. Choices A, C, and D are incorrect because a thrill upon palpation, distended blood vessels, and a swishing sound upon auscultation are expected findings in a client with an arteriovenous fistula and do not necessarily indicate a complication.

5. A client with COPD is receiving discharge teaching. Which statement indicates an understanding of the teaching?

• A. I will avoid breathing deeply while using my incentive spirometer.
• B. I will limit my fluid intake to 1 liter per day.
• C. I will exercise in an area that is humid.
• D. I will use pursed-lip breathing techniques.

Correct answer: D

Rationale: The correct answer is D. Using pursed-lip breathing techniques is beneficial for clients with COPD as it helps control shortness of breath by keeping airways open longer. Option A is incorrect as deep breathing while using an incentive spirometer is essential to prevent complications such as atelectasis. Option B is incorrect because limiting fluid intake to 1 liter per day is not a standard recommendation for clients with COPD. Option C is incorrect as exercising in a humid area can exacerbate breathing difficulties for clients with COPD.

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