Nursing Elites

1. During an admission history, a client tells a nurse that she is under a lot of stress. Which of the following physiological responses should the nurse expect to increase as a result of stress?

• A. Blood glucose - a common stress response.
• B. Intestinal peristalsis - should decrease due to stress.
• C. Peripheral blood vessels diameter - can vary in response to stress.
• D. Urine output - may vary but not a typical stress response.

Correct answer: A

Rationale: The correct answer is A. Stress typically increases blood glucose levels due to the release of stress hormones like cortisol and adrenaline. Elevated blood glucose helps provide energy for the body to cope with the stressful situation. Choice B is incorrect because intestinal peristalsis, the movement of the intestines, is more likely to decrease under stress due to the 'fight or flight' response. Choice C is incorrect as peripheral blood vessels' diameter may vary in response to stress, with both constriction and dilation possible. Choice D is incorrect as urine output may increase or decrease depending on individual differences and the specific stress response, but it is not a typical or direct physiological response to stress.

2. A female client's significant other has been at her bedside providing reassurances and support for the past 3 days, as desired by the client. The client's estranged husband arrives and demands that the significant other not be allowed to visit or be given condition updates. Which intervention should the nurse implement?

• A. Obtain a perception from the healthcare provider regarding visitation privileges
• B. Request a consultation with the ethics committee for resolution of the situation
• C. Encourage the client to speak with her husband regarding his disruptive behavior
• D. Communicate the client's wishes to all members of the multidisciplinary team

Correct answer: D

Rationale: The correct intervention is to communicate the client's wishes to all members of the multidisciplinary team. This action respects the client's autonomy and maintains her comfort by ensuring that her desires regarding visitation and support are known and upheld. Obtaining a perception from the healthcare provider regarding visitation privileges (Choice A) may not fully consider the client's preferences. Requesting a consultation with the ethics committee (Choice B) may be premature and could delay prompt resolution of the issue. Encouraging the client to speak with her husband (Choice C) may not be appropriate, as the husband's demands are disrupting the client's care and comfort, and the client may not feel safe or comfortable doing so.

3. A nurse is planning care for a client who reports abdominal pain. An assessment by the nurse reveals the client has a temperature of 39.2°C (102°F), heart rate of 105/min, a soft tender abdomen, and menses overdue by 2 days. Which of the following findings should be the nurse’s priority?

• A. Temperature
• B. Menses overdue
• C. Soft tender abdomen
• D. Heart rate

Correct answer: A

Rationale: The correct answer is A: Temperature. A high temperature of 39.2°C (102°F) indicates a fever, which can be a sign of infection or another serious condition. Investigating the cause of the fever is a priority to address any underlying health issue promptly. Menses overdue (choice B) could be relevant but is not as urgent as addressing a fever. A soft tender abdomen (choice C) is important but may be a consequence of the underlying condition causing the fever. Heart rate (choice D) is also significant, but the priority here is to identify the cause of the fever.

4. While changing a client's postoperative dressing, the nurse observes a red and swollen wound with a moderate amount of yellow and green drainage and a foul odor. Given there is a positive MRSA, which is the most important action for the nurse to take?

• A. Force oral fluids
• B. Request a nutrition consult
• C. Initiate contact precautions
• D. Limit visitors to immediate family only

Correct answer: C

Rationale: The correct action for the nurse to take in this situation is to initiate contact precautions. MRSA (Methicillin-resistant Staphylococcus aureus) is a highly contagious bacterium that spreads through direct contact. Contact precautions involve wearing gloves and gowns to prevent the spread of infection to other patients or healthcare workers. Force-feeding oral fluids, requesting a nutrition consult, or limiting visitors to immediate family only are not the most appropriate actions in this scenario. These actions do not directly address the need to prevent the spread of MRSA, which is crucial in a healthcare setting.

5. A healthcare provider is delegating client care to assistive personnel. Which of the following tasks should the healthcare provider delegate?

• A. Evaluating healing of an incision
• B. Inserting an NG Tube
• C. Performing a simple dressing change
• D. Changing IV tubing

Correct answer: C

Rationale: The correct task that a healthcare provider should delegate to assistive personnel is performing a simple dressing change. Assistive personnel are trained and competent in performing basic wound care activities like simple dressing changes. Evaluating the healing of an incision requires clinical judgment and assessment skills that are typically performed by licensed healthcare professionals, such as nurses or physicians. Inserting an NG tube and changing IV tubing involve invasive procedures that require specialized training and skills, making them tasks that should be performed by licensed healthcare providers rather than assistive personnel.

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