Nursing Elites

1. The nurse instructs the patient about incentive spirometry as part of preoperative teaching. Which phase of the nursing process does this illustrate?

• A. Assessment
• B. Planning
• C. Implementation
• D. Evaluation

Correct answer: C

Rationale: Instructing a patient about incentive spirometry falls under the implementation phase of the nursing process. During this phase, nursing interventions are put into action. Assessment (choice A) involves collecting data about the patient's condition, planning (choice B) involves setting goals and creating a care plan, and evaluation (choice D) involves assessing the outcomes of nursing interventions. Therefore, the correct answer is C, as it reflects the active teaching and intervention part of the process.

2. A nurse is performing a cultural assessment of a group of clients to maintain respect for their value systems and beliefs. Which of the following should the nurse identify as examples of cultural variables?

• A. Eye contact
• B. Personal space
• C. Touch
• D. All of the above

Correct answer: D

Rationale: In a cultural assessment, it is essential to consider various cultural variables that can impact communication and interactions. Eye contact, personal space, and touch are examples of cultural variables that can vary among different cultural groups. These variables influence how individuals perceive and engage in communication. Understanding and respecting these differences are crucial for effective and culturally sensitive care. Therefore, the correct answer is 'All of the above.' Choices A, B, and C are incorrect because each of them represents a cultural variable that should be considered during a cultural assessment.

3. A nurse is assessing a client who has schizophrenia and is experiencing negative symptoms. Which of the following findings should the nurse expect?

• A. Hallucinations
• B. Delusions
• C. Flat affect
• D. Paranoia

Correct answer: C

Rationale: The correct answer is C: Flat affect. Negative symptoms of schizophrenia involve deficits in normal emotional responses or other thought processes. These symptoms include a flat affect (reduced emotional expression), social withdrawal, and avolition (lack of motivation). Hallucinations and delusions are characteristic of positive symptoms, which involve the presence of abnormal behaviors or experiences. Paranoia is more associated with delusions rather than negative symptoms.

4. A nurse is caring for a client prescribed sildenafil for erectile dysfunction. Which of the following should the nurse monitor?

• A. Blood pressure
• B. Heart rate
• C. Temperature
• D. Respiratory rate

Correct answer: A

Rationale: The correct answer is A: Blood pressure. Sildenafil, a medication for erectile dysfunction, can cause changes in blood pressure. The nurse should monitor for hypotension as a potential side effect. Monitoring heart rate (choice B) is not a priority when administering sildenafil unless there are pre-existing heart conditions. Temperature (choice C) and respiratory rate (choice D) are typically not directly affected by sildenafil administration, making them less relevant for monitoring in this case.

5. A nurse receives a report from an assistive personnel that a client's BP is 160/95. What should the nurse do first?

• A. Notify the healthcare provider
• B. Recheck the client's BP
• C. Document the findings
• D. Administer antihypertensive medication

Correct answer: B

Rationale: The correct answer is to recheck the client's BP. It is essential for the nurse to verify the accuracy of the initial reading by reassessing the blood pressure. Notifying the healthcare provider or administering antihypertensive medication should only occur after confirming the elevated blood pressure through a recheck. Documenting the findings is important but should follow the confirmation of the BP reading.

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