Nursing Elites

1. A client expresses doubt about the benefits of surgery. Which response by the nurse is most appropriate?

• A. Ask the client to explain why they believe the surgery won't help.
• B. Comment on the client's doubt regarding the procedure's benefits.
• C. Assure the client that everything will be fine.
• D. Acknowledge the client's uncertainty about the surgery.

Correct answer: D

Rationale: Option D is the most appropriate response as it acknowledges the client's expressed uncertainty about the surgery. By acknowledging the client's feelings, the nurse validates their concerns and opens the door for further discussion. This approach can help build trust and rapport with the client. Option A focuses more on seeking justification for the client's belief rather than addressing the underlying emotion. Option B, while acknowledging doubt, does not directly address the client's feelings. Option C, although well-intentioned, dismisses the client's concerns without exploring them further.

2. What is the main symptom of left-sided heart failure?

• A. Shortness of breath
• B. Edema
• C. Increased heart rate
• D. Decreased urine output

Correct answer: A

Rationale: Shortness of breath is the main symptom of left-sided heart failure because it results from pulmonary congestion due to fluid buildup in the lungs. Edema, increased heart rate, and decreased urine output are associated with right-sided heart failure rather than left-sided heart failure.

3. Which of the following findings should the nurse anticipate in the medical record of a client with a pressure ulcer?

• A. Serum albumin level of 3 g/dL
• B. Braden scale score of 20
• C. Norton scale score of 18
• D. Hemoglobin level of 13 g/dL

Correct answer: A

Rationale: The correct answer is A: Serum albumin level of 3 g/dL. A serum albumin level of 3 g/dL indicates poor nutrition, which is commonly seen in clients with pressure ulcers. Choice B, a Braden scale score of 20, is incorrect because a higher Braden scale score indicates a lower risk of developing pressure ulcers. Choice C, a Norton scale score of 18, is incorrect as it is a tool used to assess the risk of developing pressure ulcers, not a finding in a client with an existing pressure ulcer. Choice D, a hemoglobin level of 13 g/dL, is unrelated to pressure ulcers and does not directly reflect the nutritional status associated with this condition.

4. A nurse is contributing to the plan of care for a client following a transurethral resection of the prostate (TURP). Which of the following interventions should the nurse include?

• A. Administer antibiotics
• B. Irrigate the bladder using sterile technique
• C. Avoid irrigating the bladder
• D. Insert a urinary catheter

Correct answer: B

Rationale: Irrigating the bladder using sterile technique is crucial in the care of a client following a transurethral resection of the prostate (TURP). This intervention helps prevent infection and maintains patency of the urinary catheter, promoting healing. Administering antibiotics (Choice A) may be necessary if there is an infection present, but it is not a routine intervention following TURP. Avoiding bladder irrigation (Choice C) is not recommended as it can lead to clot retention and other complications. Inserting a urinary catheter (Choice D) is usually already done during the TURP procedure and is not a postoperative intervention.

5. What are the risk factors for developing pneumonia in older adults?

• A. Immobility and decreased lung function
• B. Poor hygiene and aspiration
• C. Use of respiratory equipment and medications
• D. Poor nutritional status and compromised immune system

Correct answer: A

Rationale: The correct answer is A: Immobility and decreased lung function. Older adults with immobility and decreased lung function are at a higher risk of developing pneumonia. Immobility can lead to decreased lung expansion and impaired clearance of secretions, predisposing to pneumonia. While poor hygiene, aspiration, use of respiratory equipment, medications, poor nutritional status, and compromised immune system can also contribute to pneumonia risk, they are not as directly associated with pneumonia in older adults as immobility and decreased lung function.

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