Nursing Elites

1. While being prepared for transport to the operating room, a client scheduled for hysterectomy informs the nurse that she no longer wants to have surgery. What action should the nurse take?

• A. Notify the provider about the client's decision
• B. Proceed with the transport
• C. Prepare the surgical site
• D. Document the client’s statement

Correct answer: A

Rationale: The correct action for the nurse to take in this situation is to notify the provider about the client's decision. By informing the provider, they can discuss the client's change in decision, explore the reasons behind it, and determine the appropriate course of action. Proceeding with the transport (Choice B) without addressing the client's concerns would not respect the client's autonomy and right to make decisions about their own healthcare. Preparing the surgical site (Choice C) would be premature and inappropriate if the client no longer wishes to proceed with the surgery. While documenting the client's statement (Choice D) is important for documentation purposes, the immediate priority is to involve the provider in the decision-making process.

2. The healthcare provider is planning care for a 3-month-old infant immediately postoperative following placement of a ventriculoperitoneal shunt for hydrocephalus. The healthcare provider needs to

• A. Assess for abdominal distention
• B. Maintain the infant in an upright position
• C. Begin feeding formula when the infant is alert
• D. Pump the shunt to assess for proper function

Correct answer: A

Rationale: Assessing for abdominal distention is crucial in this situation as it can indicate a complication with the shunt or fluid accumulation. Abdominal distention may suggest an issue with the shunt placement, such as obstruction or overdrainage, which requires immediate intervention. Maintaining the infant in an upright position (Choice B) is not the priority immediately postoperatively following a ventriculoperitoneal shunt placement. Beginning formula feedings when the infant is alert (Choice C) may be appropriate but is not the priority over assessing for abdominal distention. Pumping the shunt to assess for proper function (Choice D) is not a recommended nursing intervention postoperatively and should be done by a qualified healthcare provider.

3. The client with chronic obstructive pulmonary disease (COPD) is being educated about lifestyle changes. Which statement by the client indicates a need for further teaching?

• A. I will reduce my salt intake.
• B. I will exercise for 30 minutes most days of the week.
• C. I will drink alcohol only on the weekends.
• D. I will monitor my blood pressure regularly.

Correct answer: C

Rationale: The correct answer is C. Clients with COPD should limit alcohol intake, not just to weekends, to effectively manage their condition. Excessive alcohol consumption can worsen respiratory symptoms and interfere with medications. Choices A, B, and D are all appropriate and beneficial for clients with COPD. Salt intake reduction helps in managing fluid retention and blood pressure. Regular exercise improves lung function and overall health. Monitoring blood pressure is crucial for individuals with COPD as hypertension is a common comorbidity.

4. At 0100 on a male client's second postoperative night, the client states he is unable to sleep and plans to read until feeling sleepy. What action should the nurse implement?

• A. Stay with the client and offer assistance with relaxation techniques
• B. Assess the client's pain level and administer pain medication if needed
• C. Bring the client a prescribed PRN sedative-hypnotic
• D. Encourage the client to engage in a quiet, non-stimulating activity until feeling sleepy

Correct answer: C

Rationale: At 0100 on the client's second postoperative night, the nurse should address the client's inability to sleep. Providing a prescribed PRN sedative-hypnotic is appropriate in this situation to help the client rest. Choice A is incorrect because leaving the room and closing the door does not directly address the client's sleep concern. Choice B is not the priority at this moment since the client's main issue is insomnia, not pain. Choice D, while encouraging a non-stimulating activity, does not provide immediate relief for the client's sleeplessness as a sedative-hypnotic would.

5. A nurse is discussing the nursing process with a newly licensed nurse. Which of the following statements by the newly licensed nurse should the nurse identify as appropriate for the planning step of the nursing process?

• A. “I will determine the most important client problems that we should address.”
• B. “I will review the past medical history on the client’s record to gather more information.”
• C. “I will carry out the new prescriptions from the provider.”
• D. “I will ask the client if their nausea has resolved.”

Correct answer: A

Rationale: In the nursing process, the planning step involves determining priorities and goals based on the identified problems. Choice A is correct as it reflects the nurse's role in identifying the most important client problems to address, which aligns with the planning phase. Choices B, C, and D are incorrect. Choice B involves data collection, which is a part of the assessment phase, not planning. Choice C pertains to the implementation of care, which occurs after the planning phase. Choice D involves evaluation of a specific intervention, not planning.

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