Nursing Elites

1. A nurse is observing bonding between a client and her newborn. Which of the following actions by the client requires the nurse to intervene?

• A. Holding the newborn in an en face position
• B. Asking the father to change the newborn's diaper
• C. Requesting the nurse to take the newborn to the nursery so she can rest
• D. Viewing the newborn's actions as uncooperative

Correct answer: D

Rationale: The correct answer is D because viewing the newborn's actions as uncooperative indicates a lack of bonding, which requires intervention. Choices A, B, and C all involve appropriate and caring actions by the client towards the newborn. Holding the newborn in an en face position promotes bonding, involving the father in caring for the newborn is beneficial for family involvement, and requesting rest by asking the nurse to take the newborn to the nursery is a responsible action to ensure both the client and the newborn get adequate rest.

2. A nurse is caring for a client who is comatose and has advance directives that indicate the client does not want life-sustaining measures. The client's family wants the client to have life-sustaining measures. Which of the following actions should the nurse take?

• A. Arrange for an ethics committee meeting to address the family's concerns
• B. Support the family's decision and initiate life-sustaining measures
• C. Complete an incident report
• D. Encourage the family to contact an attorney

Correct answer: A

Rationale: In this scenario, the nurse should arrange for an ethics committee meeting to address the family's concerns while ensuring the client's wishes are respected. Choosing option A allows for a formal discussion involving healthcare professionals, family members, and possibly a legal expert to navigate the situation ethically and legally. Supporting the family's decision to initiate life-sustaining measures (option B) would disregard the client's advance directives and autonomy. Completing an incident report (option C) is not appropriate in this situation as it does not address the conflict of interest between the family's desires and the client's wishes. Encouraging the family to contact an attorney (option D) may escalate the situation unnecessarily before exploring more ethical and collaborative approaches.

3. What is the primary nursing action for a patient with confusion post-surgery?

• A. Administer oxygen
• B. Reposition the patient
• C. Monitor vital signs
• D. Check oxygen saturation

Correct answer: A

Rationale: Administering oxygen is the primary nursing action for a patient with confusion post-surgery because it helps address any potential hypoxia that may be contributing to the patient's confusion. While repositioning the patient, monitoring vital signs, and checking oxygen saturation are important nursing interventions, administering oxygen takes precedence in ensuring adequate oxygenation levels, which is crucial in managing post-surgery confusion.

4. What is the best position for a patient experiencing shortness of breath?

• A. Supine position
• B. Semi-Fowler's position
• C. Trendelenburg position
• D. Prone position

Correct answer: B

Rationale: The best position for a patient experiencing shortness of breath is the Semi-Fowler's position. This position promotes lung expansion and improves oxygenation by allowing the chest to expand more fully. The Supine position (lying flat on the back) may worsen breathing difficulties by reducing lung capacity. The Trendelenburg position (feet elevated higher than the head) is not recommended for patients with shortness of breath as it can increase pressure on the diaphragm and compromise breathing. The Prone position (lying face down) is also not suitable for patients experiencing shortness of breath as it may further restrict breathing.

5. A client who practices Orthodox Judaism informs the nurse that he cannot eat certain foods during the Passover holiday. Which of the following actions should the nurse include in the plan of care?

• A. Serve chicken with cream sauce
• B. Avoid serving fish with fins and scales
• C. Provide unleavened bread
• D. Avoid serving foods containing lamb

Correct answer: C

Rationale: During the Passover holiday, individuals practicing Orthodox Judaism adhere to specific dietary restrictions, which include consuming unleavened bread. Providing unleavened bread aligns with the client's religious beliefs and dietary requirements. Choices A, B, and D are incorrect. Serving chicken with cream sauce, avoiding fish with fins and scales, and avoiding foods containing lamb are not directly related to the dietary restrictions observed during the Passover holiday in Orthodox Judaism.

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