Nursing Elites

1. If a client refuses surgery, but the family insists, what should the nurse do in this situation?

• A. Respect the family's decision and proceed with the surgery.
• B. Respect the client's decision and notify the healthcare provider.
• C. Try to mediate between the family and the client.
• D. Encourage the client to follow their family's wishes.

Correct answer: B

Rationale: In this situation, the nurse should respect the client's decision and notify the healthcare provider. The client has the right to refuse treatment, and the nurse must advocate for the client's autonomy. Proceeding with the surgery against the client's wishes would violate their autonomy and ethical principles. Trying to mediate between the family and the client may be appropriate, but ultimately, the client's decision should be respected. Encouraging the client to follow their family's wishes disregards the client's autonomy and is not ethically appropriate.

2. What is the most important action for the nurse to take after finding a patient on the floor who reports, 'I fell out of bed'?

• A. Reassess the patient.
• B. Complete an incident report.
• C. Notify the health care provider.
• D. Take no action, as no harm has occurred.

Correct answer: C

Rationale: The most important action for the nurse to take after finding a patient on the floor who reports falling out of bed is to notify the health care provider. This is crucial to ensure that the incident is reported, documented, and that the patient receives necessary follow-up care. Reassessing the patient is important, but notifying the healthcare provider takes precedence to address any potential injuries or issues that may have resulted from the fall. Completing an incident report is necessary, but immediate notification to the healthcare provider is more critical in this situation. Doing nothing is not an appropriate response, as the patient's safety and well-being must be the top priority.

3. A home health nurse is teaching about chest physiotherapy (CPT) treatments to a client with COPD. Which of the following client statements should the nurse identify as an indication that the teaching has been understood?

• A. My coughing will decrease during CPT treatments.
• B. CPT treatments will decrease my respiratory infections.
• C. I will perform postural drainage after eating meals.
• D. CPT treatments will help cure my COPD.

Correct answer: B

Rationale: The correct answer is B because chest physiotherapy (CPT) helps reduce respiratory infections by loosening mucus in the lungs. Choice A is incorrect because coughing may temporarily increase during CPT treatments as mucus is being cleared. Choice C is incorrect because postural drainage is typically performed before meals. Choice D is incorrect because while CPT can help manage symptoms and improve lung function in COPD, it does not cure the disease.

4. A patient with diabetes is admitted with high blood sugar levels. What is the nurse's priority intervention?

• A. Administer insulin as prescribed.
• B. Encourage the patient to exercise regularly.
• C. Encourage the patient to drink water.
• D. Provide the patient with a low-sugar diet.

Correct answer: A

Rationale: Administering insulin is the priority intervention for a patient admitted with high blood sugar levels because it helps lower the blood sugar levels effectively and rapidly. Insulin is a crucial medication for managing hyperglycemia in diabetes. Encouraging exercise (choice B) can be beneficial in the long term for managing blood sugar levels but is not the most immediate priority. While staying hydrated (choice C) is important, it is not the priority intervention when dealing with high blood sugar levels. Providing a low-sugar diet (choice D) is essential for long-term diabetes management but is not the immediate action needed to address high blood sugar levels in an admitted patient.

5. The healthcare provider is assessing how a patient's pain is affecting mobility. Which assessment question is most appropriate?

• A. What activities, if any, has your pain prevented you from doing?
• B. When does your pain medication typically take effect on your pain?
• C. Would you please rate your pain on a scale from 0 to 10 for me?
• D. Have you considered working with a physical therapist?

Correct answer: A

Rationale: The most appropriate assessment question in this scenario is asking the patient, 'What activities, if any, has your pain prevented you from doing?' This question helps the healthcare provider understand how pain is impacting the patient's daily activities and mobility, providing valuable insight into the limitations caused by the pain. Choice B focuses on pain medication effectiveness, which is not directly related to mobility assessment. Choice C aims at pain intensity assessment but does not directly address mobility issues. Choice D suggests a solution rather than gathering information about the current impact of pain on mobility.

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