Nursing Elites

1. When caring for an immobile client, what nursing diagnosis has the highest priority?

• A. Risk for fluid volume deficit.
• B. Impaired gas exchange.
• C. Risk for impaired skin integrity.
• D. Altered tissue perfusion.

Correct answer: B

Rationale: When caring for an immobile client, the nursing diagnosis with the highest priority is impaired gas exchange. This is because impaired gas exchange implies difficulty with breathing, which is essential for sustaining life. Adequate oxygenation is crucial for all bodily functions, and any impairment in gas exchange can lead to serious complications, making it the priority nursing diagnosis to address in an immobile client. Choices A, C, and D are important considerations as well when caring for an immobile client, but they are secondary to impaired gas exchange. Risk for fluid volume deficit may occur due to immobility, but ensuring proper gas exchange takes precedence as it directly impacts the client's immediate survival. Risk for impaired skin integrity is a concern in immobile clients but does not pose an immediate threat to life like impaired gas exchange. Altered tissue perfusion is also critical but is usually a consequence of impaired gas exchange, reinforcing the priority of addressing gas exchange first.

2. A client has a nursing diagnosis of 'Spiritual distress related to a loss of hope, secondary to impending death.' What intervention is best for the nurse to implement when caring for this client?

• A. Help the client accept the final stage of life.
• B. Assist and support the client in establishing short-term goals.
• C. Encourage the client to make future plans, even if they are unrealistic.
• D. Instruct the client's family to focus on positive aspects of the client's life.

Correct answer: B

Rationale: When a client is experiencing spiritual distress due to a loss of hope related to impending death, it is crucial for the nurse to assist and support the client in establishing short-term goals. This approach helps the client maintain hope and a sense of purpose, as achieving immediate goals can provide a sense of accomplishment and meaning. While acceptance of the final stage of life is important, helping the client set short-term goals is a more immediate and effective intervention in addressing spiritual distress. Encouraging the client to make future plans, especially if they are unrealistic, may not be beneficial as it could lead to further distress if those plans are unattainable. Instructing the client's family to focus on positive aspects of the client's life, though supportive, does not directly address the client's spiritual distress and loss of hope.

3. Which client is most likely to be at risk for spiritual distress?

• A. Roman Catholic woman considering an abortion
• B. Jewish man considering hospice care for his wife
• C. Seventh-day Adventist in need of a blood transfusion
• D. Muslim man in need of a total knee replacement

Correct answer: A

Rationale: The correct answer is A. In Roman Catholicism, abortion is strictly prohibited, so a Roman Catholic woman considering this procedure may experience spiritual distress due to conflicts with her religious beliefs. This conflict can lead to emotional and psychological turmoil, affecting her spiritual well-being. It is essential for healthcare providers to recognize and address such conflicts with sensitivity and understanding to provide holistic care.

4. The client was placed in restraints due to confusion while hospitalized. The family removes the restraints in the client's presence. After the family leaves, what should the nurse do first?

• A. Apply the restraints to ensure the client's safety.
• B. Reassess the client to determine if restraints are still necessary.
• C. Document the time the family departed and continue monitoring the client.
• D. Contact the healthcare provider for a new order.

Correct answer: B

Rationale: In this scenario, the nurse's initial action should be to reassess the client to determine if restraints are still necessary following their removal by the family. This reassessment is crucial to evaluate the client's current condition and the need for restraints before considering reapplication. By reassessing first, the nurse ensures that the client's safety is maintained while respecting their autonomy. While documentation and monitoring are important, reassessment takes priority to provide individualized and appropriate care to the client. Contacting the healthcare provider for a new order should occur after reassessment if restraints are deemed necessary.

5. During a urethral catheterization on a female, where would the healthcare provider observe the urethral meatus after separating the labia?

• A. Between the vaginal orifice and the anus.
• B. Between the clitoris and the vaginal orifice.
• C. Just above the clitoris.
• D. Within the vaginal canal.

Correct answer: B

Rationale: The correct location of the urethral meatus in females is between the clitoris and the vaginal orifice. When performing a urethral catheterization, it is crucial to identify this anatomical landmark for correct insertion of the catheter. Choice A is incorrect as the urethral meatus is not located between the vaginal orifice and the anus. Choice C is incorrect as the urethral meatus is not located just above the clitoris. Choice D is incorrect as the urethral meatus is not within the vaginal canal.

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