Nursing Elites

1. A male Native American presents to the clinic with complaints of frequent abdominal cramping and nausea. He states that he has chronic constipation and had not had a bowel movement in five days, despite trying several home remedies. Which intervention is most important for the nurse to implement?

• A. Evaluate the stool samples for the presence of blood
• B. Assess for the presence of an impaction
• C. Determine which home remedies were used
• D. Obtain a list of prescribed medications

Correct answer: B

Rationale: Assessing for impaction is crucial as it is a common cause of constipation and abdominal discomfort. In this scenario, the patient's symptoms of chronic constipation and no bowel movement for five days despite trying home remedies indicate a potential impaction that needs to be assessed. Evaluating stool samples for blood, determining the home remedies used, or obtaining a list of prescribed medications, while potentially relevant, are not as urgent as assessing for impaction in this situation.

2. A nurse observes an assistive personnel (AP) preparing to obtain blood pressure with a regular size cuff for a client who is obese. Which of the following explanations should the nurse give the AP?

• A. Using a cuff that is too small will result in an inaccurately high reading.
• B. Using a cuff that is too large will result in an inaccurately low reading.
• C. The regular size cuff is appropriate for all clients.
• D. You should use a cuff of any size as long as it fits.

Correct answer: A

Rationale: The correct answer is A: 'Using a cuff that is too small will result in an inaccurately high reading.' When obtaining blood pressure for an obese client, it is crucial to use a larger cuff to ensure an accurate reading. Choice B is incorrect because using a cuff that is too large for an obese client would actually result in an inaccurately low reading. Choice C is incorrect as a regular size cuff is not appropriate for obese clients due to their larger arm circumference. Choice D is incorrect because using a cuff of any size as long as it fits is not suitable for obtaining accurate blood pressure readings on an obese client.

3. A client with pneumonia is receiving antibiotic therapy. Which finding indicates that the treatment is effective?

• A. Decreased white blood cell count
• B. Decreased respiratory rate
• C. Increased breath sounds
• D. Increased heart rate

Correct answer: C

Rationale: The correct answer is C: Increased breath sounds. When a client with pneumonia is receiving antibiotic therapy, increased breath sounds indicate that the lungs are clearing and the pneumonia is resolving. This improvement in breath sounds suggests that the antibiotics are effectively treating the infection. Choices A, B, and D are incorrect because a decreased white blood cell count, decreased respiratory rate, and increased heart rate are not specific indicators of the effectiveness of antibiotic therapy in treating pneumonia. While these parameters may change in response to treatment, they do not directly reflect the resolution of the pneumonia infection.

4. A client is incontinent of loose stool and is reporting a painful perineum. Which of the following is the priority nursing action?

• A. Assess the client's perineum
• B. Administer pain medication
• C. Clean the area with a mild cleanser
• D. Apply a barrier cream to the affected area

Correct answer: A

Rationale: Assessing the client's perineum is the priority nursing action in this situation. By checking the perineum, the nurse can evaluate for skin damage, irritation, infection, or other issues that may be causing the client's pain. This assessment is crucial to determine the appropriate interventions needed to address the client's discomfort and prevent complications. Administering pain medication, cleaning the area with a mild cleanser, or applying a barrier cream are important interventions but should follow the initial assessment of the perineum to ensure comprehensive care and effective management of the client's condition. Prioritizing assessment allows for a targeted and individualized approach to care, enhancing the client's overall well-being.

5. A healthcare professional is planning teaching for a group of adolescents who each recently had surgical placement of an ostomy. Which of the following methods should the healthcare professional use as a psychomotor approach to learning?

• A. Practice sessions
• B. Demonstrations
• C. Written instructions
• D. Group discussions

Correct answer: A

Rationale: Practice sessions are an effective psychomotor approach to learning for adolescents with ostomies as they involve hands-on practice of ostomy care skills, which can help reinforce learning through active engagement. Demonstrations (choice B) can be helpful in providing visual guidance but may not offer the same level of active participation and practice as practice sessions. Written instructions (choice C) may be useful for reference but may not be as effective in developing psychomotor skills. Group discussions (choice D) focus more on verbal exchange and may not directly address the need for hands-on skill development required in managing ostomies. Therefore, practice sessions are the most suitable method for enhancing psychomotor learning in this scenario.

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