Nursing Elites

1. An older adult client just diagnosed with colon cancer asks the nurse what the primary care provider is going to do. The provider will be making rounds within the hour. Which of the following nursing actions is appropriate?

• A. Help the client write down the questions to ask the provider, so that the client doesn’t forget
• B. Reassure the client that everything will be explained
• C. Explain the procedure in detail yourself
• D. Direct the client to search for information online

Correct answer: A

Rationale: Assisting the client in preparing questions is the most appropriate action as it helps ensure that all concerns are addressed during the provider's visit. By helping the client write down questions, the nurse empowers the client to actively participate in their care and communicate effectively with the provider. Reassuring the client, while well-intentioned, may not address the specific questions or fears the client has. Explaining the procedure in detail may not be what the client is seeking at this moment, as their primary concern is about the provider's actions. Directing the client to search for information online is not recommended as it may lead to confusion or misinformation, and the information may not be tailored to the client's specific situation.

2. The mother of a toddler calls the nurse for help as the baby is choking on his food. The nurse determines that the Heimlich maneuver is necessary based on which finding?

• A. Inability of the toddler to cry or speak
• B. Coughing forcefully
• C. Gagging but able to breathe
• D. Wheezing during respiration

Correct answer: A

Rationale: The correct answer is option A: Inability of the toddler to cry or speak. In cases of choking, the inability to cry or speak indicates a severe airway obstruction where the Heimlich maneuver is necessary to clear the obstruction and establish a patent airway. Option B, coughing forcefully, represents a partial obstruction where the child can still move air, making the Heimlich maneuver not immediately necessary. Option C, gagging but able to breathe, suggests a partial obstruction where air is moving, and the child can still breathe, not requiring immediate intervention like the Heimlich maneuver. Option D, wheezing during respiration, is more indicative of a lower airway issue such as asthma rather than an upper airway obstruction that necessitates the Heimlich maneuver.

3. The patient has the nursing diagnosis of Impaired physical mobility related to pain in the left shoulder. Which priority action will the nurse take?

• A. Encourage the patient to engage in self-care.
• B. Promote mobility in the patient.
• C. Encourage the patient to perform range of motion exercises.
• D. Assist the patient with comfort measures.

Correct answer: D

Rationale: The priority action for a patient with Impaired physical mobility related to pain is to assist the patient with comfort measures. By addressing pain through comfort measures, the patient will be more willing and able to move. Encouraging self-care (Choice A) may be important but addressing pain first is crucial in improving mobility. Promoting mobility (Choice B) and encouraging range of motion exercises (Choice C) are important but addressing the pain and providing comfort measures take precedence to improve the patient's physical mobility.

4. A patient's hygiene schedule of bathing and brushing teeth is largely influenced by family customs. For which age group is the nurse most likely providing care?

• A. Adolescent
• B. Preschooler
• C. Older adult
• D. Adult

Correct answer: B

Rationale: The correct answer is B: Preschooler. Family customs have a significant impact on hygiene practices during childhood, especially in the early years. Preschoolers are at an age where they are learning and forming habits, and family customs play a crucial role in establishing routines such as bathing and brushing teeth. Adolescents, older adults, and adults are more likely to have established their own hygiene routines that may not be as heavily influenced by family customs as in early childhood. Therefore, the nurse is most likely providing care to a preschooler in this scenario.

5. A client with diabetes mellitus is being taught by a nurse about mixing regular and NPH insulin. Which of the following statements by the client indicates an understanding of the teaching?

• A. I should roll the NPH vial between my hands before drawing it up.
• B. I should draw up the NPH insulin before the regular insulin.
• C. I should inject air into the vial of regular insulin first.
• D. I should wait 10 minutes after mixing the insulin to inject it.

Correct answer: A

Rationale: The correct answer is A. Rolling the NPH vial between the hands before drawing it up ensures proper mixing of the insulin. Choice B is incorrect because regular insulin should be drawn up first to avoid contamination. Choice C is incorrect as injecting air into the vial of regular insulin is not necessary. Choice D is incorrect as there is no need to wait 10 minutes after mixing the insulin before injecting it.

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