Nursing Elites

1. The nurse notes that a depressed female client has been more withdrawn and non-communicative during the past two weeks. Which intervention is most important to include in the updated plan of care for this client?

• A. Encourage the client's family to visit more often
• B. Schedule a daily conference with the social worker
• C. Encourage the client to participate in group activities
• D. Engage the client in a non-threatening conversation

Correct answer: D

Rationale: Engaging the client in a non-threatening conversation is crucial as it can help build trust and provide support, addressing the client's withdrawal. This intervention focuses on establishing a therapeutic relationship and giving the client an opportunity to express their feelings. Choices A, B, and C do not directly target the client's need for communication and may not address the underlying issues contributing to her withdrawal. Encouraging the client's family to visit more often (Choice A) may add pressure or discomfort to the client. Scheduling a daily conference with the social worker (Choice B) may not address the client's immediate need for communication. Encouraging the client to participate in group activities (Choice C) may be overwhelming for the client and not address her withdrawal directly.

2. Which intervention should the nurse include in a long-term plan of care for a client with Chronic Obstructive Pulmonary Disease (COPD)?

• A. Reduce risk factors for infection
• B. Administer high-flow oxygen during sleep
• C. Limit fluid intake to reduce secretions
• D. Use diaphragmatic breathing to achieve better exhalation

Correct answer: D

Rationale: The correct answer is D. Diaphragmatic breathing is a beneficial intervention for clients with COPD as it helps improve breathing efficiency and manage symptoms by promoting better air exchange in the lungs. It aids in achieving better exhalation, reducing air trapping, and enhancing overall lung function. Choices A, B, and C are incorrect. While reducing risk factors for infection is important for overall health, it is not a specific long-term intervention for COPD. Administering high-flow oxygen during sleep may be necessary in some cases but is not typically a long-term strategy for managing COPD. Limiting fluid intake to reduce secretions is not recommended as hydration is essential for individuals with COPD to maintain optimal respiratory function and prevent complications like mucus plugs.

3. The nurse is teaching a class on child care to new parents. Which instruction should be included about the prevention of rotavirus infection in infants who are starting to eat foods?

• A. Keep house pets away from the food preparation area
• B. Avoid feeding infants fresh fruits
• C. Use only lactose-free formulas
• D. Wash hands before any food preparation

Correct answer: D

Rationale: The correct answer is D: Wash hands before any food preparation. Rotavirus is a highly contagious virus that can be prevented by maintaining proper hygiene. Washing hands before handling food can help prevent the spread of infections, including rotavirus. Choices A, B, and C are incorrect because while they are good practices for general hygiene and infant care, they are not specifically targeted at preventing rotavirus infection.

4. Several clients on a busy antepartum unit are scheduled for procedures that require informed consent. Which situation should the nurse explore further before witnessing the client's signature on the consent form?

• A. The client was medicated for pain with a narcotic analgesic IM 6 hours ago
• B. A 15-year-old primigravida who has been self-supporting for the past 6 months
• C. The obstetrician explained a procedure that a neurologist will perform
• D. The client is illiterate but verbalizes understanding and consent for the procedure

Correct answer: D

Rationale: The correct answer is D because an illiterate client may require additional support to ensure they fully comprehend the information provided in the informed consent process. It is crucial to confirm that the client truly understands the nature of the procedure, its risks, and benefits. While it is important to assess pain control (choice A), a client's previous medication administration does not directly impact their ability to understand the consent process. Choice B, a 15-year-old primigravida who has been self-supporting, may legally provide informed consent depending on the jurisdiction and circumstances, so this situation may not require further exploration. Choice C, explaining a procedure by a different specialist, does not necessarily require additional exploration before witnessing the client's consent.

5. The unlicensed assistive personnel (UAP) has applied a gown and gloves and secured the tops of the gloves over the gown sleeves. What action should the nurse take?

• A. Confirm that the gown is tied securely at the neck and waist
• B. Remind the UAP to wash hands frequently while in the room
• C. Assist the UAP with application of the face mask or face shield
• D. Help the UAP reposition the gown sleeve over the gloves edges

Correct answer: D

Rationale: Proper application of personal protective equipment (PPE) is crucial to maintain infection control. In this scenario, the nurse should help the UAP reposition the gown sleeve over the gloves' edges. This action ensures that the gown properly covers the gloves, reducing the risk of contamination. Choices A, B, and C are incorrect because the primary concern is to address the improper application of PPE by repositioning the gown sleeves over the gloves, not checking other aspects of PPE or reminding about hand hygiene.

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