Nursing Elites

1. A nurse is providing teaching to an older adult client who has constipation. Which of the following statements should the nurse include in the teaching?

• A. Sit on the toilet 30 minutes after eating a meal.
• B. Increase your fluid intake to help with bowel movements.
• C. Exercise regularly to improve bowel function.
• D. Consume more high-fiber foods to prevent constipation.

Correct answer: A

Rationale: The correct statement the nurse should include in the teaching is to 'Sit on the toilet 30 minutes after eating a meal.' This advice can help establish a regular bowel routine and improve bowel movement. Option B, 'Increase your fluid intake to help with bowel movements,' while important, is not specific to the time after eating and does not directly address the need for establishing a routine. Option C, 'Exercise regularly to improve bowel function,' is also important but does not address the timing of bowel movements. Option D, 'Consume more high-fiber foods to prevent constipation,' is beneficial for preventing constipation but does not address the timing aspect related to bowel movements.

2. The nurse plans to assist a male client out of bed for the first time since his surgery yesterday. His wife objects and tells the nurse to get out of the room because her husband is too ill to get out of bed.

• A. Administer nasal oxygen at a rate of 5 L/min
• B. Help the client to lie back down in the bed
• C. Quickly pivot the client to the chair and elevate the legs
• D. Check the client’s blood pressure and pulse deficit

Correct answer: D

Rationale: Checking the client’s blood pressure and pulse deficit is essential before mobilizing a client out of bed, especially after surgery. This assessment helps ensure the client's stability and readiness for mobilization. Administering oxygen or pivoting the client without prior assessment could pose risks if the client is not medically stable. Helping the client lie back down without proper evaluation may delay necessary interventions if the client is indeed ready for mobilization.

3. Which statement made by a client indicates to the nurse that they may have a thought disorder?

• A. 'I'm so angry about this. Wait until my partner hears about this.'
• B. 'I'm a little confused. What time is it?'
• C. 'I can't find my missing shoes. Have you seen them?'
• D. 'I'm fine. It's my daughter who has the problem.'

Correct answer: C

Rationale: The statement 'I can't find my missing shoes. Have you seen them?' displays disorganized thinking or speech, which is characteristic of a thought disorder. The mention of 'missing shoes' in a context that does not make logical sense suggests a disturbance in thought processes. Choices A, B, and D do not demonstrate disorganized thinking typical of thought disorders. Option A reflects emotional expression, option B indicates mild confusion, and option D shows a redirection of focus to someone else's problem.

4. The healthcare professional is caring for a client with a chest tube. Which observation requires immediate intervention?

• A. Constant bubbling in the suction control chamber
• B. Intermittent bubbling in the water seal chamber
• C. Drainage of 50 ml per hour
• D. Crepitus around the insertion site

Correct answer: D

Rationale: Crepitus around the chest tube insertion site may indicate subcutaneous emphysema, which requires immediate attention. The presence of crepitus suggests air leaking into the tissues, which could lead to respiratory compromise. Constant bubbling in the suction control chamber is expected and indicates proper functioning of the chest tube system. Intermittent bubbling in the water seal chamber is also normal, showing the system is intact. Drainage of 50 ml per hour is within the expected range for a chest tube.

5. A 54-year-old male client and his wife were informed this morning that he has terminal cancer. Which nursing intervention is likely to be most appropriate?

• A. Ask the wife how she would like to participate in the client's care
• B. Provide the wife with information about hospice
• C. Encourage the wife to visit during the treatment process
• D. Refer her to a support group for family members of those with terminal cancer

Correct answer: A

Rationale: In this situation, it is crucial to involve the wife in the care of the client to provide support and empower her. Asking the wife how she would like to participate allows her to be actively involved in decision-making and caregiving. Providing information about hospice (choice B) might be premature as the couple may still be digesting the diagnosis. Encouraging the wife to visit during the treatment process (choice C) may not address her immediate need for involvement and support. Referring her to a support group for family members (choice D) is helpful but involving her directly in the client's care is a more immediate and personalized approach.

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