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. When reinforcing teaching about self-care with a patient who has pelvic inflammatory disease and does not speak English, what action by the nurse is appropriate?

• A. Provide written instructions in English.
• B. Use family members as translators.
• C. Seek assistance from a facility-approved interpreter.
• D. Use online translation tools.

Correct answer: C

Rationale: When communicating with a patient who does not speak English, it is crucial to seek assistance from a facility-approved interpreter. Using family members as translators can lead to inaccuracies, breaches in confidentiality, and discomfort for the patient. Online translation tools may not provide accurate or context-specific translations, which can result in misunderstandings. Providing written instructions in English would not be effective if the patient does not understand the language.

3. Before an amniocentesis, what action by the client will need to be completed?

• A. Increase fluid intake
• B. Empty the bladder
• C. Avoid eating for 12 hours
• D. Take a sedative

Correct answer: B

Rationale: Before an amniocentesis, the client should empty their bladder. This is necessary to reduce the risk of bladder puncture during the procedure. A full bladder can be in the path of the needle, increasing the risk of injury. Increasing fluid intake (choice A) is not necessary before an amniocentesis. Avoiding eating for 12 hours (choice C) is not a standard preparation for an amniocentesis. Taking a sedative (choice D) is not routinely required for this procedure.

4. A nurse is teaching a client with gestational diabetes about blood sugar control. Which of the following statements indicates understanding?

• A. I should test my blood sugar before each meal.
• B. I can eat any foods as long as I take my insulin.
• C. I should avoid all carbohydrates in my diet.
• D. I will only need to monitor my blood sugar at bedtime.

Correct answer: A

Rationale: The correct answer is A: 'I should test my blood sugar before each meal.' Monitoring blood sugar before meals is crucial for managing gestational diabetes as it helps in understanding how different foods affect blood sugar levels and adjusting insulin doses accordingly. Choice B is incorrect as food choices should be monitored carefully, not just relying on insulin. Choice C is incorrect because while it is important to manage carbohydrate intake, completely avoiding all carbohydrates is not recommended. Choice D is incorrect as blood sugar monitoring throughout the day is essential, not just at bedtime, to ensure proper control and management of gestational diabetes.

5. A client with preeclampsia is receiving magnesium sulfate intravenously. What action should the nurse take if the client develops toxicity?

• A. Position the client supine
• B. Prepare an IV bolus of dextrose 5%
• C. Administer calcium gluconate IV
• D. Administer methylergonovine IM

Correct answer: C

Rationale: In cases of magnesium sulfate toxicity, calcium gluconate is the antidote as it helps reverse the effects. Positioning the client supine (Choice A) may not directly address magnesium sulfate toxicity. Administering dextrose 5% (Choice B) is not the correct intervention for magnesium sulfate toxicity. Methylergonovine IM (Choice D) is used to manage postpartum hemorrhage, not magnesium sulfate toxicity.

Similar Questions