Nursing Elites

1. A client with cardiovascular disease is being taught by a nurse how to reduce sodium and cholesterol intake. The nurse understands that the most significant factor in planning dietary changes for this client is:

• A. Client’s financial resources
• B. Involvement of the client in planning the change
• C. Availability of low-sodium foods
• D. Frequency of dietary counseling sessions

Correct answer: B

Rationale: The most significant factor in planning dietary changes for a client with cardiovascular disease is the involvement of the client in planning the change. By involving the client in the planning process, the nurse ensures that the client takes ownership of their health and is more likely to adhere to and succeed in modifying dietary habits. This empowerment and engagement enhance the client's motivation and commitment to making sustainable changes. Financial resources, availability of low-sodium foods, and frequency of dietary counseling sessions are important considerations but are not as crucial as the client's active involvement in the planning process.

2. The nurse is caring for a client with a central venous catheter. What is the most important action for the nurse to take to prevent infection?

• A. Change the catheter dressing every 72 hours.
• B. Flush the catheter with heparin solution daily.
• C. Ensure the catheter is clamped when not in use.
• D. Maintain sterile technique when handling the catheter.

Correct answer: D

Rationale: Maintaining sterile technique when handling a central venous catheter is crucial in preventing infections. Changing the catheter dressing every 72 hours, while important for overall catheter care, does not directly address infection prevention. Flushing the catheter with heparin solution daily is essential for maintaining patency but does not primarily prevent infections. Ensuring the catheter is clamped when not in use is important for preventing air embolism but is not the most critical action to prevent infection. The most effective way to prevent infections is by strictly adhering to sterile techniques during catheter handling, which minimizes the risk of introducing pathogens into the catheter site.

3. During the check-up of a 2-month-old infant at a well-baby clinic, the mother expresses concern to the nurse because a flat pink birthmark on the baby's forehead and eyelid has not gone away. What is an appropriate response by the nurse?

• A. Mongolian spots are a normal finding in dark-skinned infants.
• B. Port wine stains are typically associated with other malformations.
• C. Telangiectatic nevi are normal and will disappear as the baby grows.
• D. The child is too young for surgical removal of these at this time.

Correct answer: C

Rationale: The correct answer is C. Telangiectatic nevi, often referred to as 'stork bites,' are common birthmarks in infants and are considered normal. These birthmarks usually fade and disappear as the child grows older. Choices A, B, and D are incorrect because Mongolian spots are bluish-gray birthmarks commonly found in darker-skinned infants, port wine stains are vascular birthmarks that typically do not disappear, and surgical removal is not recommended for telangiectatic nevi as they usually resolve on their own.

4. A client is reporting pain to a nurse. When documenting the quality of the client's pain on an initial pain assessment, the nurse should record which of the following client statements?

• A. "I'm having mild pain."
• B. "The pain is like a dull ache in my stomach."
• C. "I notice that the pain gets worse after I eat."
• D. "The pain makes me feel nauseous."

Correct answer: B

Rationale: The correct answer is B. When documenting the quality of pain, it is essential to record the client's description of how the pain feels in their own words. Choice A simply states the intensity of pain but does not describe its quality. Choices C and D provide information related to aggravating factors and associated symptoms, respectively, but they do not describe the quality of pain. Therefore, choice B, which describes the pain as a dull ache in the stomach, is the most appropriate statement to document for assessing the quality of the client's pain.

5. The nurse manager has been using a decentralized block scheduling plan to staff the nursing unit. However, staff have asked for many changes and exceptions to the schedule over the past few months. The manager considers self-scheduling knowing that this method will

• A. Improve the quality of care
• B. Decrease staff turnover
• C. Minimize the amount of overtime payouts
• D. Improve team morale

Correct answer: D

Rationale: The correct answer is D: 'Improve team morale.' Self-scheduling allows staff more control over their work hours, which can lead to increased job satisfaction, autonomy, and a sense of ownership over their schedules. This, in turn, fosters a positive work environment, enhances collaboration among team members, and boosts morale. Choices A, B, and C are incorrect because while self-scheduling may indirectly contribute to improved quality of care, decreased staff turnover, and minimized overtime payouts, the primary benefit in this context is the positive impact on team morale.

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