Nursing Elites

1. A client with end-stage heart failure who is awaiting a transplant appears depressed and states, 'I know a transplant is my last chance, but I don't want to become a vegetable.' How should the nurse respond?

• A. Would you like information about advance directives?
• B. I will arrange for a psychiatrist to speak with you.
• C. Do you want to come off the transplant list?
• D. Would you like to speak with a priest or chaplain?

Correct answer: A

Rationale: The client is expressing a fear of negative outcomes related to the transplant. By offering information about advance directives, the nurse allows the client to discuss concerns and preferences for end-of-life care. This response shows empathy, acknowledges the client's autonomy, and addresses the client's fears while providing support and information.

2. A nurse is assessing a client who has COPD. The nurse should expect the client's chest to be which of the following shapes?

• A. Pigeon
• B. Funnel
• C. Kyphotic
• D. Barrel

Correct answer: D

Rationale:

3. A nurse cares for a female client who has a family history of cystic fibrosis. The client asks, Will my children have cystic fibrosis? How should the nurse respond?

• A. Since many of your family members are carriers, your children will also be carriers of the gene.
• B. Cystic fibrosis is an autosomal recessive disorder. If you are a carrier, your children will have the disorder.
• C. Since you have a family history of cystic fibrosis, I would encourage you & your partner to be tested.
• D. Cystic fibrosis is caused by a protein that controls the movement of chloride. Adjusting your diet will decrease the spread of this disorder.

Correct answer: C

Rationale: Cystic fibrosis is an autosomal recessive disorder in which both gene alleles must be mutated for the disorder to be expressed. The nurse should encourage both the client & partner to be tested for the abnormal gene. The other statements are not true.

4. A client is 12 hours postoperative following colon resection. Which of the following interventions should the nurse include in the plan to reduce respiratory complications?

• A. Use incentive spirometer every 4 hours while awake.
• B. Initiate ambulation after discontinuing the NG tube.
• C. Maintain a supine position with an abdominal binder.
• D. Splint the incision to support coughing every 2 hours.

Correct answer: D

Rationale: Following a colon resection surgery, it is essential to support the incision site to reduce the risk of respiratory complications. Splinting the incision helps to minimize pain during coughing, aiding in effective clearing of secretions and preventing respiratory problems. This intervention supports the client's respiratory function postoperatively, promoting optimal recovery.

5. A client has been diagnosed with hypertension but does not take the antihypertensive medications because of a lack of symptoms. What response by the nurse is best?

• A. Do you have trouble affording your medications?
• B. Most people with hypertension do not have symptoms.
• C. You are lucky; most people get severe morning headaches.
• D. You need to take your medicine or you will get kidney failure.

Correct answer: B

Rationale: Most people with hypertension are asymptomatic, although a small percentage do have symptoms such as headache. The nurse should explain this to the client. Asking about paying for medications is not related because the client has already admitted nonadherence. Threatening the client with possible complications will not increase compliance.

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