Nursing Elites

1. An experienced nurse tells the nurse-manager that working with a new graduate is impossible because the new graduate will not listen to suggestions. The new graduate comes to the nurse-manager describing the senior nurse's attitude as challenging and offensive. What action is best for the nurse manager to take?

• A. Have both nurses meet separately with the staff mental health consultant
• B. Listen actively to both nurses and offer suggestions to solve the dilemma
• C. Ask the senior nurse to examine mentoring strategies used with the new graduate
• D. Ask the nurses to meet with the nurse-manager to identify ways of working together

Correct answer: D

Rationale: Facilitating a meeting for the nurses to identify ways of working together is the best action for the nurse manager. This approach promotes open communication, collaboration, and allows both nurses to express their concerns and perspectives. Option A may not address the underlying issues between the nurses and involving a mental health consultant may not be necessary at this stage. Option B, while listening is important, may not fully resolve the conflict without a structured plan. Option C focuses solely on the senior nurse without involving the new graduate in resolving the situation.

2. The nurse working in an emergency center collects physical evidence 6 hours following a reported sexual assault. After placing the samples in sealed containers, which action is most important for the nurse to implement?

• A. Maintain possession of the evidence collection kit at all times until submitted to law enforcement
• B. Provide discharge instructions for prophylactic antibiotics, pregnancy, and HIV prevention medication
• C. Document the characteristics of the various sites of sample collection
• D. Assist the client with toileting, hygiene, and dressing with clean clothes

Correct answer: A

Rationale: Maintaining possession of the evidence collection kit at all times until submitted to law enforcement is crucial to ensure the integrity of the chain of custody. This step helps prevent tampering or contamination of the evidence, which is vital for the legal process. Providing discharge instructions for medications, documenting sample characteristics, and assisting the client with personal care are important aspects of care but not the immediate priority when handling forensic evidence in a sexual assault case.

3. While assessing a client who is experiencing Cheyne-Stokes respirations, the nurse observes periods of apnea. What action should the nurse implement?

• A. Elevate the head of the client's bed
• B. Auscultate the client's breath sounds
• C. Measure the length of the apneic periods
• D. Suction the client's oropharynx

Correct answer: C

Rationale: When a nurse observes periods of apnea in a client experiencing Cheyne-Stokes respirations, measuring the length of the apneic periods is essential. This action helps in determining the severity of Cheyne-Stokes respirations by providing valuable information about the duration of interrupted breathing cycles. Elevating the head of the client's bed (Choice A) may be beneficial in some respiratory conditions but is not the priority in Cheyne-Stokes respirations. Auscultating the client's breath sounds (Choice B) is a general assessment and may not directly address the issue of apnea in Cheyne-Stokes respirations. Suctioning the client's oropharynx (Choice D) is not the initial intervention for managing Cheyne-Stokes respirations unless secretions are obstructing the airway.

4. A client with chronic renal failure is receiving peritoneal dialysis. The nurse notes that the client's dialysate output is less than the input and that the client's abdomen is distended. What action should the nurse take first?

• A. Turn the client from side to side
• B. Increase the dwell time of the dialysis
• C. Reposition the client
• D. Milk the catheter

Correct answer: A

Rationale: The correct first action for the nurse to take is turning the client from side to side. This helps to facilitate drainage in peritoneal dialysis. Turning the client can aid in redistributing the dialysate and promoting better drainage. Increasing the dwell time of the dialysis (choice B) may not address the immediate issue of inadequate drainage. Repositioning the client (choice C) might not be as effective as turning the client from side to side. Milking the catheter (choice D) is not recommended as it can lead to complications. In this situation, the priority is to facilitate drainage to address the distended abdomen.

5. The nurse is planning discharge teaching for a client with chronic kidney disease. Which information is most important for the nurse to provide this client?

• A. Monitor daily weights
• B. Limit fluid intake to prevent fluid overload
• C. Report any weight gain of more than 2 pounds in a day
• D. Increase protein intake to promote healing

Correct answer: C

Rationale: The most important information for the nurse to provide a client with chronic kidney disease is to report any weight gain of more than 2 pounds in a day. This is crucial because sudden weight gain can indicate fluid retention, which is a common issue in kidney disease. Monitoring daily weights, as in option A, is important but not as critical as reporting sudden weight gain. Option B, limiting fluid intake, is a general recommendation for kidney disease but not the most important aspect in this scenario. Option D, increasing protein intake, is not appropriate as excessive protein intake can be harmful for clients with kidney disease.

Similar Questions