Nursing Elites

1. A client who has a terminal illness asks several questions about the nurse's religious beliefs related to death and dying. Which of the following actions should the nurse take?

• A. Encourage the client to express their thoughts about death and dying
• B. Share the nurse's personal beliefs about death and dying
• C. Redirect the client to a chaplain or spiritual advisor
• D. Provide a brief overview of common religious beliefs about death and dying

Correct answer: A

Rationale: Encouraging the client to express their thoughts allows them to explore their own feelings and concerns about death. This approach empowers the client to reflect on their beliefs and values without the influence of the nurse's personal beliefs (choice B), which should remain separate in a professional setting. Redirecting the client to a chaplain or spiritual advisor (choice C) may be appropriate if the client seeks specific spiritual guidance. Providing a brief overview of common religious beliefs (choice D) may not address the client's individual questions and concerns.

2. When evaluating the effectiveness of a client's nursing care, the nurse first reviews the expected outcomes identified in the plan of care. What action should the nurse take next?

• A. Determine if the expected outcomes were realistic
• B. Obtain current client data to compare with expected outcomes
• C. Modify the nursing interventions to achieve the client's goals
• D. Review related professional standards of care

Correct answer: B

Rationale: After reviewing the expected outcomes in the plan of care, the nurse should obtain current client data to compare with these outcomes. This step is crucial in determining the effectiveness of the care provided. Choice A is incorrect because determining the realism of expected outcomes comes after assessing current client data. Choice C is incorrect as modifying nursing interventions should be based on the data comparison rather than done immediately after reviewing expected outcomes. Choice D is also incorrect as reviewing professional standards of care is important but not the immediate next step in evaluating care effectiveness.

3. While auscultating the anterior chest of a newly admitted patient, what would the nurse expect to hear?

• A. Normal breathing sounds
• B. Wheezing
• C. Crackles
• D. Stridor

Correct answer: A

Rationale: When auscultating the chest, normal breathing sounds are expected in a healthy individual. Wheezing is a high-pitched whistling sound that indicates narrowed airways and is often heard in conditions like asthma. Crackles are fine, crackling sounds heard on inspiration or expiration and are associated with conditions like pneumonia or heart failure. Stridor is a high-pitched, harsh sound heard during inspiration due to upper airway obstruction. Therefore, choices B, C, and D indicate abnormal respiratory findings, while choice A signifies normal breathing sounds.

4. A client who has just had a mastectomy has a closed wound suction device (hemovac) in place. Which nursing action will ensure proper operation of the device?

• A. Collapsing the device whenever it is 1/2 to 2/3 full of air.
• B. Emptying the device every 4 hours.
• C. Replacing the device every 24 hours.
• D. Keeping the device above the level of the surgical site.

Correct answer: A

Rationale: Collapsing the device when it is 1/2 to 2/3 full of air is the correct nursing action to ensure proper operation of a closed wound suction device (hemovac). This action maintains negative pressure, which is essential for proper suction and drainage of the wound. Emptying the device every 4 hours (Choice B) is not necessary as the focus should be on collapsing it appropriately. Replacing the device every 24 hours (Choice C) is not a standard practice unless indicated by the healthcare provider. Keeping the device above the level of the surgical site (Choice D) is not necessary for the device's proper operation; collapsing it to maintain negative pressure is the key action.

5. A healthcare professional is using the I-SBAR communication tool to provide the client's provider with information about the client. The healthcare professional should convey the client's pain status in which portion of the report?

• A. Assessment
• B. Situation
• C. Background
• D. Recommendation

Correct answer: A

Rationale: In the I-SBAR communication tool, the 'Assessment' portion is where the healthcare professional should convey the client's pain status. This section includes the current patient information, such as the client's pain level, to provide a comprehensive view of the client's condition. Choice B ('Situation') typically involves a brief summary of the client's problem or reason for the communication. Choice C ('Background') usually covers the client's medical history and background information. Choice D ('Recommendation') focuses on the healthcare professional's suggestions or requests regarding the client's care plan, which may include pain management strategies but not the current pain status.

Similar Questions