Nursing Elites

1. The client is being educated about depression by the nurse. Which statement by the client indicates that the teaching has been effective?

• A. ''All elderly individuals experience depression occasionally.''
• B. ''I'm relieved that I will improve within 2 or 3 days.''
• C. ''I never realized depression could occur without a specific cause.''
• D. ''Reducing stress in my life will alleviate the depression.''

Correct answer: C

Rationale: The correct answer, 'I never realized depression could occur without a specific cause,' demonstrates an understanding that depression can arise without a clear trigger, indicating effective teaching. Choice A is incorrect because not all elderly individuals experience depression, and this statement doesn't show understanding. Choice B is incorrect as it reflects a misconception about the quick resolution of depression. Choice D is incorrect as it oversimplifies the relationship between stress reduction and depression resolution.

2. You are attempting to teach the wife of a Greek patient how to administer his gastrostomy tube feedings once he returns home. She smiles and nods through your explanations, but when you ask her for a return demonstration, she looks confused and shakes her head. Her daughter enters the room and states that she does not speak English. What would be most helpful in this situation?

• A. Teach the daughter instead
• B. Teach both and ask the daughter to translate for you
• C. Contact a home health agency to provide care
• D. Provide a pamphlet with detailed instructions

Correct answer: B

Rationale: Teaching both the patient's wife and the daughter is the best option in this situation. The daughter may not always be available, and the wife is eager to care for her husband at home. While a hospital interpreter is often preferred, asking the daughter to interpret is a good alternative. This approach allows the daughter to receive instruction and reinforce it for herself as she translates it to her mother. Contacting a home health agency may not be necessary if family members are willing and able to assist. Providing a pamphlet with detailed instructions would not be as effective in ensuring the wife fully understands the procedure and can carry it out correctly.

3. Mr. Y had surgery two days ago and is recovering on the surgical unit of the hospital. Just before lunch, he develops chest pain and difficulties with breathing. His respiratory rate is 32/minute, his temperature is 100.8�F, and he has rales on auscultation. Which of the following nursing interventions is most appropriate in this situation?

• A. Place the client in the Trendelenburg position
• B. Contact the physician for an order for antibiotics
• C. Administer oxygen therapy
• D. Decrease his IV rate

Correct answer: C

Rationale: Chest pain, dyspnea, tachypnea, mild fever, and rales or crackles on auscultation in a client who had surgery 2 days ago may be indicative of a pulmonary embolism. The nurse should administer oxygen to address his breathing and assist him to a comfortable position to facilitate better oxygenation before contacting the physician. Placing the client in the Trendelenburg position is not recommended in this situation as it may worsen a potential pulmonary embolism by increasing venous return. Contacting the physician for antibiotics is not the priority as the immediate concern is addressing the breathing difficulty. Decreasing the IV rate is not indicated in this situation where the client is experiencing respiratory distress and needs oxygen therapy.

4. What question must the nurse ask when formulating a nursing diagnosis?

• A. What diagnosis did the physician make for this client?
• B. What is the issue that I can solve for this client?
• C. What physician orders will resolve this issue?
• D. What underlying disease does this client have?

Correct answer: B

Rationale: When formulating a nursing diagnosis, the nurse should focus on identifying the client's specific health problems that can be addressed through nursing interventions. The correct answer emphasizes the nurse's role in identifying and addressing client-specific issues through nursing care. Choice A is incorrect because nursing diagnoses are distinct from medical diagnoses made by physicians. Choice C is incorrect as it focuses on physician orders rather than the nurse's role in diagnosing and addressing client problems. Choice D is incorrect because it pertains to identifying underlying diseases, which is not the primary focus of nursing diagnoses.

5. A healthcare professional is preparing to draw a blood specimen from an adult client's central line. All of the following actions for this procedure are correct EXCEPT:

• A. Disconnect the current infusion
• B. Clean the cap with alcohol and attach a 5 cc syringe
• C. Draw 5 cc of a blood sample to discard
• D. Flush with saline after the sample

Correct answer: B

Rationale: When drawing a blood specimen from a central line, the healthcare professional should disconnect any infusions that are currently running and that could contaminate the specimen. It is important to use a minimum size of a 10 cc syringe when using a central line to avoid placing too much pressure on the catheter. Cleaning the cap with alcohol and attaching a 5 cc syringe is not appropriate as a larger syringe size should be used for this procedure. Drawing 5 cc of a blood sample to discard and flushing with saline after the sample are correct steps in the process of drawing a blood specimen from a central line.

Similar Questions