Nursing Elites

1. The nurse is caring for a client who has had surgery the previous day. The client tells the nurse, “Breathing in using this thing (incentive spirometer) is a ridiculous waste of time.” What is the nurse’s best response?

• A. “The spirometer will help you cough effectively.”
• B. “The spirometer will help your lungs expand.”
• C. “The spirometer will help prevent blood clots.”
• D. “The spirometer will improve blood flow in your lungs.”

Correct answer: “The spirometer will help your lungs expand.”

Rationale: The correct answer is, '“The spirometer will help your lungs expand.”' Incentive spirometry is used postoperatively to help prevent atelectasis by expanding the lungs and improving lung function. Choice A is incorrect because the primary purpose of the spirometer is not to help cough effectively. Choice C is incorrect because while deep breathing with the spirometer can indirectly help prevent blood clots by improving lung function, its primary purpose is not to prevent blood clots directly. Choice D is incorrect because although using the spirometer can improve ventilation and oxygenation, its main purpose is not to improve blood flow in the lungs.

2. What intervention is most important to teach the client about identifying the onset of dehydration?

• A. Measuring abdominal girth
• B. Converting ounces to milliliters
• C. Obtaining and charting daily weight
• D. Selecting food items with high water content

Correct answer: C: Obtaining and charting daily weight

Rationale: The correct answer is C: Obtaining and charting daily weight. Monitoring daily weight is crucial in identifying the onset of dehydration as weight loss can be an early sign. Measuring abdominal girth (choice A) is not the most reliable method for detecting dehydration. Converting ounces to milliliters (choice B) and selecting food items with high water content (choice D) may be important for overall hydration but are not the most critical interventions for identifying the onset of dehydration.

3. A female client with deteriorating neurologic function states, “I am worried I will not be able to care for my young children.” How does the nurse respond?

• A. “Caring for your children is a priority. You may not want to ask for help, but you have to.”
• B. “Our community has resources that may help you with some household tasks so you have energy to care for your children.”
• C. “You seem distressed. Would you like to talk to a psychologist about adjusting to your changing status?”
• D. “Give me more information about what worries you, so we can see if we can do something to make adjustments.”

Correct answer: “Give me more information about what worries you, so we can see if we can do something to make adjustments.”

Rationale: When a client expresses worry about not being able to care for her children due to deteriorating neurologic function, the most appropriate response from the nurse is to gather more information from the client. This open-ended approach allows the nurse to better understand the client's specific concerns and needs, leading to tailored interventions and support. Choice A is dismissive and may make the client feel guilty for needing help. Choice B focuses on external resources without addressing the client's worries directly. Choice C suggests a psychological referral without exploring the client's concerns further. Therefore, the correct response is to gather more information to provide personalized support.

4. When the client finds antiembolism stockings uncomfortably tight, what is the nurse’s best action?

• A. Remove the stockings for an hour to relieve the pressure
• B. Pull the stockings down so that they are not constricting
• C. Measure the client’s calf to ensure that they are the correct size
• D. Teach the client the purpose of wearing the stockings

Correct answer: Teach the client the purpose of wearing the stockings

Rationale: The correct action for the nurse to take when a client finds antiembolism stockings uncomfortably tight is to teach the client the purpose of wearing the stockings. This educates the client on the importance of the stockings in preventing blood clots and encourages compliance. Removing the stockings or pulling them down may compromise their effectiveness. Measuring the client's calf size is not necessary in this situation as the discomfort is due to tightness, not incorrect sizing.

5. How does the nurse interpret the client's actions of combing her hair only on the right side of her head and washing only the right side of her face after a stroke?

• A. Poor left-sided motor control
• B. Paralysis or contractures on the right side
• C. Limited visual perception of the left fields
• D. Unawareness of the existence of her left side

Correct answer: Unawareness of the existence of her left side

Rationale: The client's selective grooming and washing habits indicate a condition known as 'unawareness of the existence of her left side,' also called hemispatial neglect. This condition is characterized by a lack of awareness or attention to one side of the body or space, typically the left side in stroke patients. Choices A, B, and C are incorrect because the client's actions are not due to poor motor control, paralysis, contractures, or limited visual perception. Instead, they are indicative of a specific cognitive deficit related to neglecting one side of the body.

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