Nursing Elites

1. While undergoing fetal heart monitoring, a pregnant Native-American woman requests that a medicine woman be present in the examination room. Which of the following is an appropriate response by the nurse?

• A. "I will assist you in arranging to have a medicine woman present."?
• B. "We do not allow medicine women in exam rooms."?
• C. "That does not make any difference in the outcome."?
• D. "It is old-fashioned to believe in that."?

Correct answer: A

Rationale: The correct response is to show cultural awareness and acceptance by offering to assist in arranging for the medicine woman to be present. This demonstrates respect for the client's beliefs and preferences. Choice B is inappropriate as it dismisses the client's request without considering its cultural significance. Choice C is dismissive and does not acknowledge the client's values. Choice D is disrespectful and judgmental, undermining the client's beliefs. Therefore, the only appropriate and professional response is to support the client's request and offer assistance in accommodating it.

2. The LPN is checking for residual before administering enteral feeding through a PEG tube. Which of these steps is incorrect?

• A. The LPN elevates the head of the bed by at least 30 degrees.
• B. If the residual is greater than 200mL, the LPN should not administer the enteral feeding.
• C. The LPN should discard the residual before administering the tube feeding.
• D. The residual pH level is tested to ensure appropriate placement.

Correct answer: C

Rationale: The incorrect step is choice C. The residual should be discarded before administering the tube feeding. Discarding the residual is essential to prevent contamination and ensure accurate measurement of the enteral feeding. Elevating the head of the bed by at least 30 degrees (choice A) is correct as it helps prevent aspiration during feeding. Testing the pH level of the residual (choice D) ensures proper placement of the tube. Withholding feeding if the residual is greater than 200mL (choice B) is crucial to prevent overfeeding, making this statement correct.

3. When documenting in the client’s record, what type of information should be recorded?

• A. educated predictions of outcomes
• B. personal opinions
• C. objective information
• D. subjective information

Correct answer: C

Rationale: When documenting in a client's record, it is crucial to record objective information. Objective information is factual, based on observations and measurable data. This type of information is essential for accurate and effective communication among healthcare professionals involved in the client's care. Choices A and B, educated predictions of outcomes and personal opinions, are subjective in nature and may not provide an accurate representation of the client's condition. Choice D, subjective information, includes personal feelings, interpretations, and opinions, which are not ideal for documentation as they can be biased and unreliable.

4. An Asian family has an elderly member with the latest stage of Alzheimer's disease. The physician has recommended placement in a long-term care facility, but the family refuses. Which of the following is an appropriate response by the nurse?

• A. "You really need to listen to what the physician says."?
• B. "You will get too tired to take care of him at home."?
• C. "What can I do to assist you to care for him at home?"?
• D. "You are too busy to be taking care of an elderly person."?

Correct answer: C

Rationale: The correct answer is, "What can I do to assist you to care for him at home?"? This response shows cultural sensitivity and respect for the family's values. In many Asian cultures, there is a strong tradition of caring for elders at home rather than in a long-term care facility. By offering assistance to the family in caring for their elderly member at home, the nurse shows understanding and support. Choices A, B, and D are incorrect because they do not acknowledge or respect the family's cultural beliefs and values regarding caring for elderly family members.

5. A nurse is planning task assignments for the day. Which task should the nurse assign to the nursing assistant?

• A. Suctioning a client who requires periodic suctioning
• B. Assessing a client who has undergone an arteriogram and requires close monitoring
• C. Performing colostomy irrigation on a client with an ostomy
• D. Assisting a client who needs frequent ambulation with a walker

Correct answer: D

Rationale: When delegating tasks, a nurse must consider the staff member's education and competency level. Noninvasive tasks like helping a client ambulate with a walker are usually suitable for nursing assistants. Suctioning a client and colostomy irrigation are invasive procedures that require a licensed nurse's skills. Assessing a client post-arteriogram for any complications or changes in condition also necessitates the expertise of a licensed nurse. Therefore, the most appropriate task to assign to a nursing assistant is assisting a client who needs frequent ambulation with a walker.

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