Nursing Elites

1. 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.

2. An adult has a coagulation time of 20 minutes. The nurse should observe the client for which of the following?

• A. Blood clots
• B. Ecchymotic areas
• C. Jaundice
• D. Infection

Correct answer: B

Rationale: A coagulation time of 20 minutes is prolonged, suggesting a potential bleeding disorder. Ecchymotic areas, which are areas of bruising, are common signs of abnormal bleeding. Therefore, the nurse should observe the client for ecchymotic areas to monitor for potential bleeding issues. Blood clots are not typically associated with prolonged coagulation time but rather with excessive clotting. Jaundice is related to liver dysfunction, and infection is not directly linked to coagulation time.

3. During a client assessment, the healthcare provider is evaluating cranial nerve function. Which assessment finding suggests that cranial nerve II is intact?

• A. The client can hear a whisper from 1 to 2 feet away.
• B. The client can identify an object by touch.
• C. The client can shrug the shoulders against resistance.
• D. The client can read a Snellen chart from 20 feet away.

Correct answer: D

Rationale: The ability to read a Snellen chart from 20 feet away indicates intact cranial nerve II (optic nerve), responsible for vision. Hearing a whisper (A) is associated with cranial nerve VIII (vestibulocochlear nerve), identifying an object by touch (B) is related to cranial nerves V (trigeminal nerve) and VII (facial nerve), and shoulder shrugging against resistance (C) is a test for cranial nerve XI (accessory nerve). Thus, the correct answer is D as it specifically tests the function of cranial nerve II.

4. Which assessment data would provide the most accurate determination of proper placement of a nasogastric tube?

• A. Aspirating gastric contents to assure a pH value of 4 or less.
• B. Hearing air pass in the stomach after injecting air into the tubing.
• C. Examining a chest x-ray obtained after the tubing was inserted.
• D. Checking the remaining length of tubing to ensure that the correct length was inserted.

Correct answer: C

Rationale: The most accurate method to confirm the proper placement of a nasogastric tube is by examining a chest x-ray obtained after the tubing was inserted. This visual assessment allows healthcare providers to directly visualize the position of the tube in relation to anatomical landmarks, ensuring it is correctly placed in the stomach. Aspirating gastric contents or hearing air pass may provide some information but are not as definitive as a chest x-ray for confirming placement. Checking the remaining length of tubing is not a reliable method for determining proper placement as it does not indicate where the tip of the tube lies within the body.

5. When taking a client's blood pressure, the healthcare professional is unable to distinguish the point at which the first sound was heard. What is the best action for the healthcare professional to take?

• A. Deflate the cuff completely and immediately reattempt the reading.
• B. Reinflate the cuff completely and leave it inflated for 90 to 110 seconds before taking the second reading.
• C. Deflate the cuff to zero and wait 30 to 60 seconds before reattempting the reading.
• D. Document the exact level visualized on the sphygmomanometer where the first fluctuation was seen.

Correct answer: C

Rationale: The correct action when unable to distinguish the point of the first sound during blood pressure measurement is to deflate the cuff to zero and wait 30 to 60 seconds before reattempting the reading. This allows blood flow to return to the extremity, ensuring a more accurate reading the second time. It is important to ensure that the cuff is fully deflated and the appropriate wait time is given to obtain an accurate blood pressure measurement.

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