Nursing Elites

1. What is the best outcome for a patient with the nursing diagnosis: Impaired social interaction related to sociocultural dissonance, as evidenced by stating, “Although I’d like to, I don’t join in because I don’t speak the language very well?” The patient will:

• A. demonstrate improved social skills
• B. express a desire to interact with others
• C. become more independent in decision-making
• D. select and participate in one group activity per day

Correct answer: select and participate in one group activity per day

Rationale: The correct outcome for the patient with impaired social interaction related to sociocultural dissonance is to select and participate in one group activity per day. This outcome focuses on increasing social involvement, which aligns with addressing the nursing diagnosis. The patient has already expressed a desire to interact with others, so the goal is to facilitate actual participation in social activities. Becoming more independent in decision-making and demonstrating improved social skills are not directly related to the specific nursing diagnosis provided. Additionally, the outcomes must be measurable, making choices A and C less appropriate as they lack specificity and measurability.

2. A patient's urine specimen tested positive for bilirubin. Which of the following is most true?

• A. The patient should be evaluated for kidney disease
• B. The specimen was probably left at room temperature for more than two hours
• C. The specimen is positive for bacteria
• D. The specimen should be stored in an area protected from light

Correct answer: The specimen should be stored in an area protected from light

Rationale: Bilirubin is easily broken down by light, so all samples testing positive for bilirubin should be protected from light exposure. Storing the specimen in an area protected from light helps maintain the integrity of the bilirubin levels for accurate testing. Choice A is incorrect because the presence of bilirubin in urine does not necessarily indicate kidney disease. Choice B is incorrect as the exposure to light, not room temperature, affects bilirubin levels. Choice C is incorrect as the presence of bilirubin does not indicate the presence of bacteria in the specimen.

3. Following hospitalization for congestive heart failure, a client is discharged. The nurse teaching the family suggests they encourage the client to rest frequently in which of the following positions?

• A. High Fowler's
• B. Supine
• C. Left lateral
• D. Low Fowler's

Correct answer: High Fowler's

Rationale: The correct answer is High Fowler's. Sitting in a chair or resting in a bed in the high Fowler's position helps decrease the cardiac workload and facilitates breathing in clients with congestive heart failure. This position helps reduce venous return and increases lung expansion, improving oxygenation. The supine position (choice B) may lead to increased pressure on the heart and lungs, making it less suitable for these clients. The left lateral position (choice C) is not as effective as High Fowler's in reducing cardiac workload and improving breathing. Low Fowler's position (choice D) does not provide the same benefits as the High Fowler's position for clients with congestive heart failure.

4. When providing endotracheal suctioning, for how long should the nurse suction the endotracheal tube of an intubated client on a ventilator at a time?

• A. Five seconds or less
• B. Ten seconds or less
• C. At least 30 seconds
• D. No longer than 60 seconds

Correct answer: Ten seconds or less

Rationale: When providing endotracheal suctioning, the nurse should suction for no longer than ten seconds at a time. Suctioning for longer than ten seconds may cause hypoxia or bronchospasm. Extended suctioning may also place the client at risk of injury to the bronchial and tracheal structures. Choices C and D suggest prolonged suctioning durations that can lead to adverse effects on the client. Choice A, suctioning for five seconds or less, may not be adequate to clear secretions effectively, making choice B the most appropriate duration for safe and efficient suctioning in this scenario.

5. When examining an older adult, which technique should the nurse use?

• A. Minimize touching the patient as much as possible.
• B. Attempt to perform the entire physical examination during one visit.
• C. Speak loudly and slowly due to potential hearing deficits in aging adults.
• D. Arrange the sequence of the examination to allow as few position changes as possible.

Correct answer: D: Arrange the sequence of the examination to allow as few position changes as possible.

Rationale: When examining an older adult, it is crucial to arrange the sequence of the examination to minimize position changes. This helps prevent discomfort and fatigue for the older adult, who may have mobility issues. Option A is incorrect because physical touch is essential when examining older adults, as their other senses may be diminished. Option B is incorrect as it is better to break the examination into multiple visits to ensure thoroughness and comfort. Option C is incorrect because while some older adults may have hearing deficits, it is not appropriate to assume this for all individuals without proper assessment.

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