Nursing Elites

1. A nurse is counseling an older adult who describes having difficulty with several issues. Which of the following problems verbalized by the client should the nurse identify as the priority?

• A. “I spent my whole life dreaming about retirement, and now I wish I had my job back.”
• B. “It’s been so stressful for me to have to depend on my child to help around the house.”
• C. “I just heard my friend Al die. That’s the third one in 3 months.”
• D. “I keep forgetting which medications I have taken during the day.”

Correct answer: C

Rationale: The correct answer is C. The statement expressing the loss of friends is the priority issue as it indicates potential grief and emotional distress. Losing multiple friends within a short period can have a profound impact on an older adult's emotional well-being. Option A expresses regret but does not indicate an immediate emotional crisis. Option B focuses on stress related to dependence, which is important but not as urgent as coping with loss. Option D highlights a memory concern, which is significant but does not address the emotional impact of loss.

2. When preparing to apply dressing to a stage 2 pressure injury, which type of dressing should the nurse use?

• A. Hydrocolloid
• B. Gauze
• C. Transparent film
• D. Alginate

Correct answer: A

Rationale: The correct answer is A: Hydrocolloid. Hydrocolloid dressings are recommended for stage 2 pressure injuries as they help maintain a moist wound environment, which supports the healing process. Gauze (choice B) is not ideal for stage 2 pressure injuries as it can stick to the wound bed and disrupt the healing process. Transparent film dressings (choice C) are more suitable for superficial wounds or as a secondary dressing. Alginate dressings (choice D) are typically used for wounds with heavy exudate, which is not typically seen in stage 2 pressure injuries.

3. A nurse is caring for a client who is postoperative and has signs of hemorrhagic shock. When the nurse notifies the surgeon, he directs her to continue to measure the client's vitals every 15 minutes and call him back in 1 hour. From a legal perspective, which of the following actions should the nurse take next?

• A. Notify the nursing manager.
• B. Document the client's condition and communication with the surgeon.
• C. Administer additional fluids as per standard procedure.
• D. Call the surgeon back immediately to ensure timely intervention.

Correct answer: B

Rationale: In this scenario, the nurse should choose option B, which is to document the client's condition and communication with the surgeon. By documenting the client's condition and the communication with the surgeon, the nurse ensures legal protection and maintains continuity of care. This documentation serves as evidence of the actions taken, communication exchanged, and the rationale behind decisions made. Option A, notifying the nursing manager, may not be necessary at this stage unless there are specific institutional protocols requiring it. Administering additional fluids without further clarification may not be appropriate and could worsen the client's condition if not indicated. Calling the surgeon back immediately (option D) may disrupt the agreed-upon plan of action and fail to follow the surgeon's instructions of reassessment after an hour.

4. Following change-of-shift report on an orthopedic unit, which client should the nurse see first?

• A. 16-year-old who had an open reduction of a fractured wrist 10 hours ago
• B. 20-year-old in skeletal traction for 2 weeks since a motorcycle accident
• C. 72-year-old recovering from surgery after a hip replacement 2 hours ago
• D. 75-year-old who is in skin traction prior to planned hip pinning surgery

Correct answer: C

Rationale: The 72-year-old recovering from surgery after a hip replacement 2 hours ago should be seen first due to the potential for immediate post-operative complications. This patient is in the immediate postoperative period and requires close monitoring for any signs of complications such as bleeding, infection, or impaired circulation. The other patients are relatively stable compared to the patient who just had surgery and therefore can wait for assessment and care without immediate risk. The 16-year-old had surgery ten hours ago, which is longer than the 72-year-old and is at a lower risk for immediate complications. The 20-year-old in skeletal traction for two weeks is stable in his current condition. The 75-year-old in skin traction before planned surgery does not require immediate attention as the surgery has not yet taken place.

5. A client is admitted to the hospital in the terminal stage of cancer. The nurse enters the client’s room to administer medications and finds the client crying. The appropriate nursing action is to:

• A. Sit and hold the client’s hand
• B. Ask why the client is crying
• C. Leave the room to give the client privacy
• D. Administer the medications and leave

Correct answer: A

Rationale: In end-of-life care, providing comfort and emotional support is essential. Sitting with the client, holding their hand, and offering a compassionate presence can help the client feel supported during a difficult time. Asking why the client is crying may not always be necessary as the focus should be on providing comfort rather than probing for information. Leaving the room to provide privacy or just administering medications and leaving may neglect the client's emotional needs and miss an opportunity to provide holistic care.

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