Nursing Elites

1. A male client with acquired immunodeficiency syndrome (AIDS) develops cryptococcal meningitis and tells the nurse he does not want to be resuscitated if his breathing stops. What action should the nurse implement?

• A. Document the client's request in the medical record.
• B. Ask the client if this decision has been discussed with his healthcare provider.
• C. Inform the client that a written, notarized advance directive is required to withhold resuscitation efforts.
• D. Advise the client to designate a person to make healthcare decisions when the client is unable to do so.

Correct answer: B

Rationale: When a client expresses the desire to not be resuscitated, it is essential to inquire if this decision has been discussed with their healthcare provider. This is important to ensure that the client's wishes are appropriately documented and legally binding through the healthcare provider's guidance. It is crucial that healthcare decisions, especially those involving life-saving measures, are well-communicated and documented to respect the client's autonomy and ensure their wishes are honored. Option A is not the best action as it does not address the need to verify discussion with the healthcare provider. Option C is incorrect as it overemphasizes the need for a notarized advance directive, which may not be immediately feasible or necessary in this urgent situation. Option D is not the most appropriate action at this time since the immediate focus should be on clarifying if the decision has been communicated with the healthcare provider.

2. What action should be implemented to prevent the formation of a sacral ulcer for an immobile client?

• A. Maintain the client in a lateral position using protective wrist and vest restraints.
• B. Position the client prone with a small pillow below the diaphragm.
• C. Raise the head and knee gatch when lying in a supine position.
• D. Transfer the client to a wheelchair close to the nursing station for observation.

Correct answer: B

Rationale: Positioning the client prone with a small pillow below the diaphragm helps maintain proper alignment and provides optimal pressure relief over the sacral area, reducing the risk of developing a pressure ulcer. This position redistributes pressure away from bony prominences, such as the sacrum, which is crucial in preventing ulcer formation in immobile clients. Choice A is incorrect because using restraints can lead to further complications and does not address pressure relief. Choice C is incorrect as raising the head and knee gatch in a supine position does not directly alleviate pressure over the sacrum. Choice D is incorrect as transferring to a wheelchair does not address pressure relief or optimal positioning to prevent sacral ulcers.

3. A CVA (stroke) patient goes into respiratory distress and is placed on a ventilator. The client’s daughter arrives with a durable power of attorney and a living will that indicates there should be no extraordinary life-saving measures. What action should the nurse take?

• A. Refer to the risk manager
• B. Notify the healthcare provider
• C. Discontinue the ventilator
• D. Review the medical record

Correct answer: B

Rationale: In this situation, the nurse should notify the healthcare provider. The healthcare provider needs to be informed to review the legal documents provided by the patient's daughter, such as the durable power of attorney and living will, which specify the patient's wishes regarding life-saving measures. The healthcare provider will be responsible for making the appropriate decision based on the legal documents and the patient's current condition. Referring to the risk manager (choice A) is not necessary as the issue at hand pertains to the patient's medical care. Discontinuing the ventilator (choice C) without healthcare provider input could go against the patient's wishes and legal documents. Reviewing the medical record (choice D) may not provide immediate guidance on the current situation and the patient's preferences regarding life-saving measures.

4. When a male client mentions his foot is hurting while watching TV with his wife, how should the nurse respond?

• A. Ask him to rate his pain on a scale of 1 to 10.
• B. Encourage him to wait until bedtime for the pill to help him sleep.
• C. Attend to an acutely ill client's needs first as the client is laughing.
• D. Instruct him in the use of deep breathing exercises for pain control.

Correct answer: A

Rationale: The correct response is to ask the client to rate his pain on a scale of 1 to 10. This helps the nurse assess the intensity of the pain and determine the appropriate pain medication. Encouraging him to wait or attend to another client's needs first are incorrect because pain management should be addressed promptly. Instructing on deep breathing exercises may be helpful but is not the initial step in addressing acute pain.

5. The client with chronic obstructive pulmonary disease (COPD) is being taught pursed-lip breathing by the nurse. What is the purpose of this technique?

• A. To promote oxygenation by removing secretions.
• B. To reduce the amount of air trapped in the lungs.
• C. To increase the amount of carbon dioxide exhaled.
• D. To slow the respiratory rate and improve air exchange.

Correct answer: C

Rationale: Pursed-lip breathing is used to increase the amount of carbon dioxide exhaled (C) in clients with chronic obstructive pulmonary disease (COPD). By doing so, it helps prevent air trapping and enhances gas exchange, ultimately improving respiratory efficiency. While removing secretions (A) and reducing air trapping (B) can be associated benefits to some extent, the primary goal of pursed-lip breathing is to optimize carbon dioxide elimination and enhance breathing mechanics. Slowing the respiratory rate (D) is not the primary purpose of pursed-lip breathing.

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