Nursing Elites

1. The nurse determines that a postoperative client's respiratory rate has increased from 18 to 24 breaths/min. Based on this assessment finding, which intervention is most important for the nurse to implement?

• A. Encourage the client to increase ambulation in the room.
• B. Offer the client a high-carbohydrate snack for energy.
• C. Force fluids to thin the client's pulmonary secretions.
• D. Determine if pain is causing the client's tachypnea.

Correct answer: D

Rationale: When a postoperative client's respiratory rate increases, it is essential to determine the underlying cause. Pain, anxiety, and fluid accumulation in the lungs can lead to tachypnea (increased respiratory rate). Therefore, the priority intervention is to assess if pain is the contributing factor. Encouraging increased ambulation may worsen oxygen desaturation in a client with a rising respiratory rate. Offering a high-carbohydrate snack is not indicated as it can increase carbon metabolism; instead, consider providing an alternative energy source like Pulmocare liquid supplement. Forcing fluids may exacerbate respiratory congestion in a client with a compromised cardiopulmonary system, potentially leading to fluid overload. Therefore, determining the role of pain in tachypnea is crucial for appropriate management.

2. When emptying 350 mL of pale yellow urine from a client's urinal, the nurse notes that this is the first time the client has voided in 4 hours. Which action should the nurse take next?

• A. Record the amount on the client's fluid output record.
• B. Encourage the client to increase oral fluid intake.
• C. Notify the healthcare provider of the findings.
• D. Palpate the client's bladder for distention.

Correct answer: A

Rationale: The correct action for the nurse to take next is to record the amount of urine output on the client's fluid output record. The urine color and volume are within normal limits, indicating adequate hydration. There is no indication of a need to encourage increased oral fluid intake or notify the healthcare provider as the findings are normal. Palpating the client's bladder for distention is unnecessary in this scenario since the client has successfully voided a normal amount of urine after 4 hours.

3. Which response would the nurse make to a client with borderline personality disorder who receives the wrong tray for lunch and becomes upset at the dietary staff regarding this mistake?

• A. 'Getting angry is not appropriate; let's address this calmly.''
• B. ''Yelling is not acceptable and won't help us resolve this issue.''
• C. 'You must eat the first tray of food, and then I'll get another tray for you.''
• D. 'It must be frustrating to get the wrong tray. I'll order another tray for you.''

Correct answer: D

Rationale: The most appropriate response from the nurse would be, ''It must be frustrating to get the wrong tray. I'll order another tray for you.'' When interacting with clients with borderline personality disorder, it is crucial for nurses to acknowledge the client's emotions empathetically and provide constructive solutions. While expressing anger is understandable, guiding the client towards a more constructive approach is essential. Yelling is not a helpful way to address the situation and threatening seclusion is inappropriate. Additionally, instructing the client to eat the first tray before receiving another one is punitive and disregards the client's preferences and rights.

4. A nurse is assigned to care for a close friend in the hospital setting. Which action should the nurse take first when given the assignment?

• A. Notify the friend that all medical information will be kept confidential.
• B. Explain the relationship to the charge nurse and ask for reassignment.
• C. Approach the client and ask if the assignment is uncomfortable.
• D. Accept the assignment but protect the client's confidentiality.

Correct answer: B

Rationale: When a nurse is assigned to care for a close friend, it is essential to maintain professional boundaries to ensure the best care for the client and the nurse. The most appropriate action for the nurse to take first is to explain the relationship to the charge nurse and ask for reassignment (B). This is important to avoid potential conflicts of interest and maintain objectivity in the care provided. Option A, notifying the friend about confidentiality, may not address the underlying issue of the conflict of interest. Option C, asking the client if the assignment is uncomfortable, may not be appropriate as it puts the client in a difficult position. Option D, accepting the assignment but protecting the client's confidentiality, does not address the conflict of interest and potential ethical issues that may arise from caring for a close friend.

5. 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 who needs a blood transfusion
• D. Muslim man who needs a total knee replacement

Correct answer: A

Rationale: The correct answer is the Roman Catholic woman considering an abortion. In the Roman Catholic faith, abortion is strictly prohibited, so making a decision regarding abortion can bring about spiritual distress. The Jewish faith does not have restrictions on hospice care. It is Jehovah's Witnesses, not Seventh-Day Adventists, who do not accept blood transfusions due to religious beliefs. Additionally, there are no religious prohibitions against joint replacement in the Muslim faith.

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