Nursing Elites

1. While assisting a client with a meal, the client suddenly grabs at their neck with both hands and appears frightened. The appropriate nursing action is to:

• A. Ask the client if they are choking
• B. Perform abdominal thrusts
• C. Call for emergency help
• D. Check the client’s airway

Correct answer: A

Rationale: The correct action when a client suddenly grabs at their neck and appears frightened is to ask if they are choking. This allows the nurse to gather more information from the client directly. Performing abdominal thrusts (choice B) should only be done if the client is unable to speak, cough, or breathe. Calling for emergency help (choice C) should be done after assessing the situation and confirming choking. Checking the client's airway (choice D) is important but should come after confirming that the client is choking.

2. When communicating with a client who is hearing impaired, what should the nurse do?

• A. Face the client and speak slowly
• B. Speak loudly and clearly
• C. Use written communication only
• D. Avoid using gestures or body language

Correct answer: A

Rationale: When communicating with a client who is hearing impaired, it is important to face the client and speak slowly. This helps the individual lip-read and understand the communication more easily. Speaking loudly can distort speech and make it harder for the person to understand. Written communication may not always be practical or accessible for the client, especially in real-time interactions. Gestures and body language can actually aid in communication by providing visual cues and context. Therefore, the best approach is to face the client, speak clearly at a moderate pace, and use gestures and body language to enhance understanding.

3. A client is refusing a blood transfusion for religious reasons. The client's partner wants the client to have the blood transfusion. Which of the following actions should the nurse take?

• A. Ask the client to consider a direct donation
• B. Withhold the blood transfusion
• C. Request a consultation with the ethics committee
• D. Ask the client's family to intervene

Correct answer: B

Rationale: The correct action for the nurse to take in this situation is to withhold the blood transfusion. The principle of autonomy ensures that a competent client has the right to refuse treatment, even if their decision conflicts with the wishes of their partner or family. Asking the client to consider a direct donation (Choice A) is not appropriate as it disregards the client's autonomy and religious beliefs. Requesting a consultation with the ethics committee (Choice C) may be considered in complex ethical dilemmas, but in this case, the client's autonomy should be respected first. Asking the client's family to intervene (Choice D) is not appropriate as the client has the right to make their own healthcare decisions based on their religious beliefs.

4. A female client's significant other has been at her bedside providing reassurances and support for the past 3 days, as desired by the client. The client's estranged husband arrives and demands that the significant other not be allowed to visit or be given condition updates. Which intervention should the nurse implement?

• A. Obtain a perception from the healthcare provider regarding visitation privileges
• B. Request a consultation with the ethics committee for resolution of the situation
• C. Encourage the client to speak with her husband regarding his disruptive behavior
• D. Communicate the client's wishes to all members of the multidisciplinary team

Correct answer: D

Rationale: The correct intervention is to communicate the client's wishes to all members of the multidisciplinary team. This action respects the client's autonomy and maintains her comfort by ensuring that her desires regarding visitation and support are known and upheld. Obtaining a perception from the healthcare provider regarding visitation privileges (Choice A) may not fully consider the client's preferences. Requesting a consultation with the ethics committee (Choice B) may be premature and could delay prompt resolution of the issue. Encouraging the client to speak with her husband (Choice C) may not be appropriate, as the husband's demands are disrupting the client's care and comfort, and the client may not feel safe or comfortable doing so.

5. A client requires an NG tube for stomach decompression. Which of the following actions should the nurse take when inserting the NG tube?

• A. Help the client take sips of water to promote insertion of the NG tube.
• B. Insert the tube without asking the client to swallow.
• C. Advance the tube continuously without pausing.
• D. Use a large-bore tube for insertion.

Correct answer: A

Rationale: The correct action when inserting an NG tube is to help the client take sips of water. This helps facilitate the insertion of the tube by promoting swallowing and passage through the esophagus. Asking the client to swallow assists in guiding the tube into the stomach. Inserting the tube without asking the client to swallow may lead to incorrect placement or discomfort. Advancing the tube continuously without pausing can cause the tube to coil in the esophagus, leading to complications. Using a large-bore tube for insertion is unnecessary and may increase the risk of injury or discomfort for the client.

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