Nursing Elites

1. A nurse is preparing a client for surgery. The client refuses to remove a religious medal. What is the nurse's best response?

• A. Ask the family to remove the medal
• B. Place the medal in a safe place for the client
• C. Allow the client to keep the medal during surgery
• D. Inform the client that the medal must be removed

Correct answer: C

Rationale: The correct answer is to allow the client to keep the medal during surgery. Clients may retain religious medals or jewelry during surgery if it does not interfere with the procedure. Asking the family to remove the medal (Choice A) may not be respecting the client's wishes. Placing the medal in a safe place for the client (Choice B) may cause distress to the client who wants to keep it. Informing the client that the medal must be removed (Choice D) disregards the client's beliefs and preferences.

2. A client is being taught about which foods to include in a low fiber diet. Which statement indicates understanding?

• A. Choosing a fresh pear would be a good snack option
• B. I should make refried beans for supper
• C. Selecting white rice as a side dish is a good choice
• D. Opting for bran cereal would be a good breakfast choice

Correct answer: C

Rationale: The correct answer is C because white rice is a low-fiber food suitable for a low-fiber diet, making it an appropriate choice. Choices A, B, and D are incorrect because fresh pear, refried beans, and bran cereal are high-fiber foods and not suitable for a low-fiber diet.

3. A nurse is planning preoperative care for a client who will undergo surgery. Which of the following is the priority action by the nurse?

• A. Discuss whether family members will assist with postoperative care
• B. Review the client's current home environment
• C. Identify the client's usual coping mechanisms
• D. Determine what the client knows about the surgery

Correct answer: D

Rationale: In the preoperative phase, determining what the client knows about the surgery is the priority. This action helps address misconceptions, provide necessary information, and ensure the client's understanding and cooperation. Choices A, B, and C are important aspects of preoperative care but assessing the client's knowledge about the surgery takes precedence to alleviate fears, enhance communication, and optimize outcomes.

4. A healthcare provider is caring for a client who has an indwelling urinary catheter. Which of the following assessment findings indicates that the catheter requires irrigation?

• A. Bladder scan shows 525 mL
• B. Absent urinary output for 1 hour
• C. Cloudy urine
• D. Bloody urine

Correct answer: A

Rationale: The correct answer is A. A large bladder scan result (525 mL) suggests catheter blockage and may require irrigation to resolve. Choice B (absent urinary output for 1 hour) could indicate a different issue such as urinary retention but does not specifically indicate the need for catheter irrigation. Choices C (cloudy urine) and D (bloody urine) may suggest infection or other urinary issues, but they do not directly indicate the need for catheter irrigation.

5. A client with HIV-1 starting therapy with ritonavir and zidovudine asks why both medications are necessary. What explanation should the nurse provide?

• A. Taking two medications ensures a faster recovery.
• B. The medications work best together to improve your immune system.
• C. Taking the 2 medications together keeps you from becoming resistant to either of them.
• D. These medications target different parts of the virus.

Correct answer: C

Rationale: The correct answer is C because taking two medications together helps prevent the development of drug resistance in HIV treatment. Choice A is incorrect because the primary goal of combination therapy is not necessarily a faster recovery. Choice B is incorrect as the main purpose of combining medications in HIV treatment is to prevent resistance rather than improving the immune system. Choice D is incorrect because while it is true that the medications may target different parts of the virus, the main reason for using both together is to prevent resistance.

Similar Questions