Nursing Elites

1. What is the main purpose of the working phase of the nurse-patient relationship?

• A. Establish a formal or informal contract that addresses the patient's problems.
• B. Implement nursing interventions that are designed to achieve expected patient outcomes.
• C. Develop rapport and trust so the patient feels supported, and the initial plan can be identified.
• D. Clearly identify the role of the nurse and establish the parameters of the professional relationship.

Correct answer: B

Rationale: The main purpose of the working phase in the nurse-patient relationship is to implement nursing interventions that are specifically tailored to achieve the expected patient outcomes. During this phase, the nurse actively works with the patient to put the care plan into action and make progress towards reaching the desired health goals. It involves the application of therapeutic communication, problem-solving, and interventions to address the patient's needs. Establishing rapport and trust is typically done in the orientation phase, while defining roles and boundaries usually occurs in the introductory phase of the relationship. Choices A, C, and D are incorrect as they describe activities more aligned with other phases of the nurse-patient relationship, such as orientation and introductory phases.

2. The nurse-manager of a skilled nursing (chronic care) unit is instructing UAPs on ways to prevent complications of immobility. Which intervention should be included in this instruction?

• A. Perform range-of-motion exercises to prevent contractures.
• B. Decrease the client's fluid intake to prevent diarrhea.
• C. Massage the client's legs to reduce the occurrence of embolisms.
• D. Turn the client from side to back every shift.

Correct answer: A

Rationale: Performing range-of-motion exercises is essential in preventing contractures, which are common complications of immobility. These exercises help maintain joint flexibility and muscle strength, reducing the risk of contractures that can lead to functional limitations or pain for the client. Choices B, C, and D are incorrect. Decreasing fluid intake does not prevent immobility complications, but it can lead to dehydration. Massaging the client's legs does not directly address the prevention of immobility complications like contractures. Turning the client from side to back every shift is important for preventing pressure ulcers but does not directly address complications of immobility like contractures.

3. When taking a client's blood pressure, the healthcare professional is unable to distinguish the point at which the first sound was heard. What is the best action for the healthcare professional to take?

• A. Deflate the cuff completely and immediately reattempt the reading.
• B. Reinflate the cuff completely and leave it inflated for 90 to 110 seconds before taking the second reading.
• C. Deflate the cuff to zero and wait 30 to 60 seconds before reattempting the reading.
• D. Document the exact level visualized on the sphygmomanometer where the first fluctuation was seen.

Correct answer: C

Rationale: The correct action when unable to distinguish the point of the first sound during blood pressure measurement is to deflate the cuff to zero and wait 30 to 60 seconds before reattempting the reading. This allows blood flow to return to the extremity, ensuring a more accurate reading the second time. It is important to ensure that the cuff is fully deflated and the appropriate wait time is given to obtain an accurate blood pressure measurement.

4. A client is admitted with a diagnosis of fluid volume excess. Which intervention should the nurse include in the client's plan of care?

• A. Encourage increased fluid intake.
• B. Place the client in a high Fowler's position.
• C. Measure the client's intake and output.
• D. Restrict dietary sodium intake.

Correct answer: D

Rationale: Restricting dietary sodium intake (D) is the most critical intervention for a client with fluid volume excess to prevent further fluid retention. Encouraging increased fluid intake (A) would exacerbate the issue by adding more fluid to the body. Placing the client in a high Fowler's position (B) is more relevant for respiratory issues than fluid volume excess. While measuring intake and output (C) is important for assessing fluid balance, restricting sodium intake is the priority as it helps manage fluid levels more effectively by reducing fluid retention.

5. The client with chronic obstructive pulmonary disease (COPD) is receiving oxygen therapy. Which intervention should the nurse implement to ensure the client’s safety?

• A. Encourage the client to use oxygen continuously
• B. Monitor the client’s respiratory rate and effort
• C. Set the oxygen flow rate at 6 liters per minute
• D. Teach the client to avoid wearing wool blankets

Correct answer: B

Rationale: Monitoring the client’s respiratory rate and effort is essential to evaluate the effectiveness of oxygen therapy and prevent complications such as respiratory depression. This intervention helps the nurse promptly detect any deterioration in the client's respiratory status and take necessary actions to ensure the client's safety. Encouraging continuous oxygen use (Choice A) may lead to oxygen toxicity. Setting the oxygen flow rate at a specific level (Choice C) without individual assessment can be inappropriate and potentially harmful. Teaching the client to avoid wearing wool blankets (Choice D) is unrelated to the safe use of oxygen therapy.

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