Nursing Elites

1. A nurse is caring for two clients who report following the same religion. Which of the following information should the nurse consider when planning care for these clients?

• A. Members of the same religion may have varying feelings about their religion.
• B. A shared religion background does not guarantee identical beliefs.
• C. The same religious beliefs can influence individuals differently.
• D. Discussing differences and commonalities in beliefs may not always be relevant.

Correct answer: C

Rationale: The correct answer is C. Religious beliefs can vary widely even among individuals of the same faith. It is essential for the nurse to recognize that the impact and interpretation of religious beliefs can differ from person to person. Choice A is incorrect as individuals within the same religion can have diverse feelings and interpretations. Choice B is incorrect because a shared religious background does not necessarily mean that individuals hold the same beliefs. Choice D is not the best course of action as discussing differences and commonalities in beliefs may not always be necessary or appropriate for providing care.

2. The patient has been in bed for several days and needs to be ambulated. Which action will the nurse take first?

• A. Maintain a narrow base of support.
• B. Dangle the patient at the bedside.
• C. Encourage isometric exercises.
• D. Suggest a high-calcium diet.

Correct answer: B

Rationale: The correct action the nurse should take first when a patient needs to be mobilized after being in bed for several days is to dangle the patient at the bedside. Dangling at the bedside is the initial step to assess the patient's tolerance to sitting up and moving. It helps prevent orthostatic hypotension and allows the nurse to evaluate the patient's response to upright positioning before attempting further ambulation. Maintaining a narrow base of support (Choice A) is related to assisting with ambulation but is not the first step. Encouraging isometric exercises (Choice C) and suggesting a high-calcium diet (Choice D) are not immediate actions needed to initiate mobilization in this scenario.

3. A client with a history of chronic obstructive pulmonary disease (COPD) is being discharged with home oxygen therapy. Which statement by the client indicates a need for further teaching?

• A. I will keep my oxygen tank upright at all times.
• B. I will not use petroleum jelly to keep my nose from drying out.
• C. I will not smoke or allow others to smoke around me.
• D. I will call my doctor if I have difficulty breathing.

Correct answer: B

Rationale: The correct answer is B. Petroleum jelly is flammable and should not be used with oxygen therapy as it can increase the risk of fire. Using petroleum jelly near oxygen can lead to a fire hazard. Choices A, C, and D are correct statements that indicate proper understanding of oxygen therapy safety measures. Choice A emphasizes the importance of keeping the oxygen tank upright to prevent leaks, choice C highlights the necessity of avoiding smoking to prevent exacerbation of COPD, and choice D encourages seeking medical help promptly in case of breathing difficulties.

4. When assessing bowel sounds, what action should a healthcare professional take?

• A. Listen to the bowel sounds before performing abdominal palpation
• B. Auscultate for 2 minutes to determine if bowel sounds are present
• C. Place the diaphragm of the stethoscope over each quadrant
• D. Ask the client to cough while auscultating

Correct answer: C

Rationale: When assessing bowel sounds, it is crucial to listen before performing any palpation as palpation can alter bowel sounds. The correct technique involves placing the diaphragm of the stethoscope over each quadrant of the abdomen to listen for bowel sounds. Auscultating for at least 5 minutes is recommended to accurately determine the presence or absence of bowel sounds. Asking the client to cough is not necessary for assessing bowel sounds and may not provide relevant information. Therefore, option C is the correct choice as it follows the appropriate procedure for assessing bowel sounds.

5. While documenting in a client’s medical record, which of the following entries should the nurse record?

• A. “Incision without redness or drainage”
• B. “Drank adequate amounts of fluid with meals”
• C. “Administered pain medication”
• D. “Oral temperature slightly elevated at 0800”

Correct answer: D

Rationale: The correct answer is D because documenting specific observations, such as an oral temperature being slightly elevated at a specific time, is crucial for monitoring the client's health status accurately. This type of information helps in assessing trends and changes in the client's condition over time. Choice A is incorrect as it lacks specificity and does not provide measurable data about the client's condition. Choice B is incorrect because it is a general statement related to client behavior rather than a specific health observation. Choice C is incorrect as it reflects an action taken by the nurse and not a direct client's condition or observation.

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