Nursing Elites

1. At the time of the first dressing change, the client refuses to look at her mastectomy incision. The LPN tells the client that the incision is healing well, but the client refuses to talk about it. What would be an appropriate response to this client's silence?

• A. It is normal to feel angry and depressed, but the sooner you deal with this surgery, the better you will feel.
• B. Looking at your incision can be frightening, but facing this fear is a necessary part of your recovery.
• C. It is OK if you don't want to talk about your surgery. I will be available when you are ready.
• D. I will ask a woman who has had a mastectomy to come by and share her experiences with you.

Correct answer: C

Rationale: In this situation, it's essential to acknowledge and respect the client's feelings and choices. Choice C is the most appropriate response as it validates the client's decision not to discuss the surgery while offering support and understanding. Giving the client space and letting them know you will be available when they are ready shows empathy and fosters trust. Choices A and B do not respect the client's autonomy and may come across as dismissive or pressuring. Choice D assumes the client needs advice from someone who has had a similar experience without considering the client's current emotional state and preferences.

2. A client with a history of hypertension is prescribed a beta-blocker. Which side effect should the nurse monitor for in this client?

• A. Increased appetite
• B. Dry mouth
• C. Nausea and vomiting
• D. Bradycardia

Correct answer: D

Rationale: The correct answer is D: Bradycardia. Beta-blockers are known to decrease heart rate, which can lead to bradycardia. This is a common side effect that nurses should monitor for in clients taking beta-blockers. Choices A, B, and C are incorrect because increased appetite, dry mouth, nausea, and vomiting are not typical side effects associated with beta-blockers. Therefore, the nurse should focus on monitoring for bradycardia in this client.

3. A charge nurse is observing a newly licensed nurse perform tracheostomy care for a client. Which of the following actions by the newly licensed nurse requires intervention?

• A. Obtaining cotton balls for the tracheostomy care
• B. Using a sterile water bottle
• C. Checking the suction equipment
• D. Wearing a sterile gown

Correct answer: A

Rationale: The correct answer is A. Obtaining cotton balls for tracheostomy care is not recommended due to the risk of fiber contamination. Sterile gauze should be used instead. Choice B, using a sterile water bottle, is a correct and appropriate action for tracheostomy care to maintain cleanliness. Choice C, checking the suction equipment, is also a necessary step to ensure it is functioning properly for the procedure. Choice D, wearing a sterile gown, is a standard precaution to maintain a sterile environment during tracheostomy care.

4. A client is lying on the bathroom floor after a nurse responds to a call light. Which of the following actions should the nurse take first?

• A. Check the client for injuries
• B. Move hazardous objects away from the client
• C. Notify the provider
• D. Ask the client to describe how she felt prior to the fall

Correct answer: A

Rationale: The nurse's priority in this situation is to assess the client for injuries. Checking for injuries first is crucial to determine the extent of harm caused by the fall and to provide immediate care. Moving hazardous objects can wait until the client's safety is ensured. Notifying the provider and asking the client about how she felt prior to the fall are important but are secondary to assessing for injuries in this urgent scenario. It is essential to address immediate physical needs before investigating the cause of the fall or notifying other healthcare team members.

5. A healthcare provider is caring for several clients who are receiving oxygen therapy. Which client should the provider assess most frequently for manifestations of oxygen toxicity?

• A. 100% oxygen via partial rebreathing mask
• B. 2 liters per minute via nasal cannula
• C. 4 liters per minute via simple mask
• D. 6 liters per minute via face mask

Correct answer: A

Rationale: When a client is receiving 100% oxygen via a partial rebreathing mask, there is a higher risk for oxygen toxicity due to the higher concentration of oxygen delivered. This client should be assessed most frequently for manifestations of oxygen toxicity. Choices B, C, and D are less likely to result in oxygen toxicity compared to 100% oxygen delivery via a partial rebreathing mask.

Similar Questions