Nursing Elites

1. A nurse is planning to insert a nasogastric tube for a client after explaining the procedure. The client states, 'You are not putting that hose down my throat.' Which of the following statements should the nurse make?

• A. 'I can see that this is upsetting you.'
• B. 'It is necessary for your treatment.'
• C. 'It will be over quickly, and you will feel better.'
• D. 'Let me explain again why this procedure is important.'

Correct answer: A

Rationale: In this situation, the nurse should acknowledge the client's feelings by stating, 'I can see that this is upsetting you.' This response validates the client's emotions and demonstrates empathy, which can help build trust and rapport. Choice B is too direct and might not address the client's emotional state. Choice C focuses on the outcome rather than the client's current distress. Choice D does not directly address the client's feelings of distress and may not effectively alleviate their anxiety.

2. During a home safety assessment for a client receiving supplemental oxygen, which observation should the nurse identify as proper safety protocol?

• A. The client uses non-acetone nail polish remover.
• B. The client uses an electric razor for shaving.
• C. The client cleans their oxygen equipment weekly.
• D. The client uses wool blankets.

Correct answer: A

Rationale: The correct answer is A. Using non-acetone nail polish remover is crucial for clients on supplemental oxygen as acetone is flammable and poses a safety risk. Acetone can react with oxygen, increasing the fire hazard. Choices B, C, and D are incorrect. Electric razors can generate sparks, which are dangerous near oxygen due to the risk of ignition. While cleaning oxygen equipment is important, the type of nail polish remover used is more critical for immediate safety. Wool blankets can create static electricity, increasing the risk of fire around oxygen due to its flammability.

3. A client reports increased pain following physical therapy. Which of the following questions should the nurse ask to assess the quality of the pain?

• A. Is the pain sharp or dull?
• B. Does the pain feel like burning or aching?
• C. Is the pain constant or intermittent?
• D. Does the pain feel like throbbing or stabbing?

Correct answer: A

Rationale: When assessing pain quality, asking if the pain is sharp or dull helps determine the nature of the pain. Sharp pain is often associated with acute conditions, while dull pain may indicate a chronic issue. Choices B, C, and D are incorrect as they do not directly address the quality of the pain in terms of sharpness or dullness.

4. What is the most important aspect for the nurse to include in the discharge plan for a client performing his own dressing changes at home following abdominal surgery?

• A. Demonstration of appropriate hand hygiene
• B. Explanation of wound care technique
• C. Review of signs and symptoms of infection
• D. Instructions for when to contact the healthcare provider

Correct answer: A

Rationale: The most critical aspect for the nurse to include in the discharge plan for a client performing his own dressing changes at home following abdominal surgery is the demonstration of appropriate hand hygiene. Proper hand hygiene is essential to prevent the introduction of infection during dressing changes. While wound care technique, signs and symptoms of infection, and instructions for contacting the healthcare provider are all important components of the discharge plan, ensuring the client understands and practices proper hand hygiene is paramount to minimize the risk of infection. This choice takes precedence as it directly addresses infection prevention during the dressing changes, which is crucial for successful post-operative recovery.

5. The pediatric clinic nurse examines a toddler with a tentative diagnosis of neuroblastoma. Findings observed by the nurse that are associated with this problem include which of these?

• A. Lymphedema and nerve palsy
• B. Hearing loss and ataxia
• C. Headaches and vomiting
• D. Abdominal mass and weakness

Correct answer: D

Rationale: The correct answer is D: Abdominal mass and weakness. In neuroblastoma, the most common presenting signs are related to the mass effect of the tumor, leading to an abdominal mass and symptoms of weakness. Lymphedema and nerve palsy (Choice A) are not typically associated with neuroblastoma. Hearing loss and ataxia (Choice B) are more indicative of other conditions like neurofibromatosis or brain tumors. Headaches and vomiting (Choice C) are more commonly seen in conditions such as brain tumors or increased intracranial pressure, but they are not specific to neuroblastoma.

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