Nursing Elites

1. A healthcare provider is providing discharge teaching to a client who does not speak the same language. Which of the following actions should the healthcare provider take?

• A. Use proper medical terms when providing instructions to the client.
• B. Offer written instructions in the client’s language.
• C. Direct verbal discharge instructions to the interpreter.
• D. Request that an assistive personnel interpret instructions for the client.

Correct answer: B

Rationale: The correct action for the healthcare provider when providing discharge teaching to a client who does not speak the same language is to offer written instructions in the client’s language. This approach helps ensure better comprehension and adherence to the instructions as the client can refer back to the written material for clarification. Choice A is incorrect because using proper medical terms may not be effective if the client does not understand the language. Choice C is incorrect since verbal instructions should be directed to the client for better understanding. Choice D is incorrect as assistive personnel may not be qualified or trained to provide accurate interpretation, risking miscommunication and potential errors in the instructions.

2. How can the LPN/LVN best handle the situation of a postoperative client being kept awake by a neighboring client with dementia who sings all night?

• A. Tell the neighboring client to stop singing.
• B. Close the doors to both clients' rooms at night.
• C. Give the complaining client the prescribed sedative as needed.
• D. Move the neighboring client to a room at the end of the hall.

Correct answer: D

Rationale: The best way to handle the situation in this scenario is to move the neighboring client to a room at the end of the hall. This solution is considerate to both clients because it addresses the issue by providing a quieter environment for the client with dementia while allowing the postoperative client to rest. Choice A is inappropriate as it does not address the root cause of the problem and may not be feasible or respectful. Choice B of closing the doors may not effectively reduce the noise disturbance. Choice C of giving the complaining client sedatives should be the last resort and not the initial solution, as it does not address the underlying issue causing the disturbance.

3. A nurse is planning to insert a nasogastric tube for a client after explaining the procedure. The client states, 'You are not putting that hose down my throat.' Which of the following statements should the nurse make?

• A. 'I can see that this is upsetting you.'
• B. 'It is necessary for your treatment.'
• C. 'It will be over quickly, and you will feel better.'
• D. 'Let me explain again why this procedure is important.'

Correct answer: A

Rationale: In this situation, the nurse should acknowledge the client's feelings by stating, 'I can see that this is upsetting you.' This response validates the client's emotions and demonstrates empathy, which can help build trust and rapport. Choice B is too direct and might not address the client's emotional state. Choice C focuses on the outcome rather than the client's current distress. Choice D does not directly address the client's feelings of distress and may not effectively alleviate their anxiety.

4. A mother of a child with a neural tube defect asks the nurse what she can do to decrease the chances of having another baby with a neural tube defect. What is the best response by the nurse?

• A. Folic acid should be taken before and after conception.
• B. Multivitamin supplements are recommended during pregnancy.
• C. A well-balanced diet promotes normal fetal development.
• D. Increased dietary iron improves the health of mother and fetus.

Correct answer: A

Rationale: The correct answer is A: 'Folic acid should be taken before and after conception.' Folic acid supplementation before and during early pregnancy has been shown to significantly reduce the risk of neural tube defects. Choice B is incorrect because while multivitamin supplements are beneficial during pregnancy, the specific focus for preventing neural tube defects is on folic acid. Choice C is a general statement about a well-balanced diet and does not specifically address neural tube defects. Choice D is incorrect as it focuses on dietary iron, which is important for overall health but not specifically proven to prevent neural tube defects.

5. During auscultation of a client experiencing chest pain worsened by inspiration, a nurse hears a high-pitched scratching sound in both systole and diastole with the diaphragm of the stethoscope placed at the left sternal border. Which of the following heart sounds should the nurse document?

• A. Pericardial friction rub
• B. Murmur
• C. S1 and S2
• D. Bruit

Correct answer: A

Rationale: The correct answer is 'Pericardial friction rub.' A pericardial friction rub is a high-pitched, scratching sound heard in both systole and diastole, which is characteristic of pericardial inflammation. This sound is different from a murmur, which is a swooshing or blowing sound due to turbulent blood flow. S1 and S2 are normal heart sounds, and a bruit is a whooshing sound caused by turbulent blood flow in an artery, not related to pericardial inflammation.

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