Nursing Elites

1. A 20-year-old female client with noticeable body odor has refused to shower for the last 3 days. She states, 'I have been told that it is harmful to bathe during my period.' Which action should the nurse take first?

• A. Accept and document the client's wish to refrain from bathing.
• B. Offer to give the client a bed bath, avoiding the perineal area.
• C. Obtain written brochures about menstruation to give to the client.
• D. Teach the importance of personal hygiene during menstruation to the client.

Correct answer: D

Rationale: The correct answer is to teach the importance of personal hygiene during menstruation to the client. While respecting the client's beliefs, it is essential to provide education on maintaining hygiene during menstruation. This empowers the client with knowledge to make informed decisions. Options A and B can be considered after providing education. Option C, obtaining brochures, is not the priority as direct communication and teaching would be more effective in addressing the client's concerns.

2. After a needle stick occurs while removing the cap from a sterile needle, which action should the nurse take?

• A. Complete an incident report.
• B. Select another sterile needle.
• C. Disinfect the needle with an alcohol swab.
• D. Notify the supervisor of the department immediately.

Correct answer: B

Rationale: After a needle stick, the needle is considered contaminated and should be discarded. The nurse should select another sterile needle to use. Completing an incident report is not necessary in this situation because the needle was sterile when the nurse was stuck and not in contact with any other person's body fluids. Notifying the supervisor immediately is not required as the situation can be managed by selecting a new needle. Disinfecting the needle with an alcohol swab is not recommended as it does not meet the standards of safe practice and infection control.

3. When observing an infant lying quietly in the bassinet with eyes open wide, what action should the nurse take in response to the infant's behavior?

• A. Brightening the lights in the room
• B. Encouraging the mother to talk to her baby
• C. Wrapping and then turning the infant to the side
• D. Beginning physical and behavioral assessments

Correct answer: B

Rationale: When an infant is lying quietly in a bassinet with eyes open wide, it indicates a quiet, alert state. This state is optimal for infant stimulation and interaction. Bright lights can be disturbing to newborns and may disrupt the mother-infant interaction. Wrapping and turning the infant to the side is typically done for a sleeping infant. While physical and behavioral assessments are important, in this scenario, the priority is to encourage mother-infant bonding and communication, as it is a valuable opportunity for interaction and stimulation.

4. What is the nurse's initial plan for providing pain relief measures during labor for a pregnant client with a history of opioid abuse?

• A. Scheduling pain medication at regular intervals
• B. Administering the medication only when the pain is severe
• C. Avoiding the administration of medication unless it is requested
• D. Recognizing that less pain medication will be needed by this client compared with other women in labor

Correct answer: A

Rationale: In a pregnant client with a history of opioid abuse, scheduling pain medication at regular intervals is the initial plan for providing pain relief during labor. This client may have a lower tolerance for pain and a greater need for pain relief. If medication is only administered when the pain is severe, larger doses may be needed, leading to increased anxiety and discomfort. Avoiding medication unless requested is not ideal, as proactive pain management is crucial during labor. Recognizing that less pain medication will be needed by this client compared with others is incorrect, as individuals with a history of opioid abuse often require more medication due to tolerance to addictive drugs.

5. When caring for a patient who speaks a different language and an interpreter is unavailable, which action by the nurse is most appropriate?

• A. Talk slowly to ensure clear understanding
• B. Speak loudly in close proximity to the patient's ears
• C. Repeat important words to emphasize their significance
• D. Use simple gestures to demonstrate meaning while communicating

Correct answer: D

Rationale: When faced with a language barrier and lacking an interpreter, using simple gestures can help convey meaning to the patient. This approach can assist in basic communication and understanding. Talking slowly may not be effective if the patient does not understand the language, and speaking loudly can be perceived as aggressive or intimidating. Repeating words may not aid comprehension if the patient is unfamiliar with the language. Therefore, using gestures is the most appropriate option in this situation.

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