Nursing Elites

1. During preoperative education, a nurse should assess a client's readiness to learn before a mastectomy. Which of the following statements should the nurse identify as an indication that the client is ready to learn?

• A. “I don’t want my spouse to see my incision.”
• B. “Will you give me pain medicine after the surgery?”
• C. “Can you tell me about how long the surgery will take?”
• D. “My roommate listens to everything I say.”

Correct answer: C

Rationale: The correct answer is C. Asking about the duration of the surgery indicates readiness to learn about the procedure. This question shows that the client is actively seeking information about the surgical process, demonstrating readiness to learn. Choices A, B, and D reflect concerns, specific requests, or statements unrelated to the learning process. They do not directly indicate readiness to absorb information about the upcoming mastectomy.

2. A nurse is preparing change of shift report after the night shift using one SBAR communication tool. Which of the following data should the nurse include when reporting background information?

• A. “Blood pressure 160/92 mm Hg”
• B. “Start the first dose of penicillin at 1200”
• C. “Pain rating of 5 on a scale from 0 to 10”
• D. “Code status: do-not-resuscitate”

Correct answer: B

Rationale: The correct answer is B. When providing background information in a shift report using the SBAR communication tool, the nurse should include details related to medication administration and orders. This helps ensure continuity of care and accurate handover of responsibilities. Choices A, C, and D do not typically fall under background information for shift reports. A blood pressure reading, pain rating, and code status are more relevant to the patient's current condition and status, rather than background information about medications or orders.

3. An adult client is found to be unresponsive on morning rounds. After checking for responsiveness and calling for help, the next action that should be taken by the nurse is to:

• A. Check the carotid pulse
• B. Deliver 5 abdominal thrusts
• C. Give 2 rescue breaths
• D. Open the client's airway

Correct answer: D

Rationale: In this scenario, the priority is to ensure the client has a clear airway to facilitate breathing. After verifying unresponsiveness and calling for help, the nurse should open the client's airway to aid in maintaining ventilation. Checking the carotid pulse (Choice A) may be important but comes after ensuring a clear airway. Delivering abdominal thrusts (Choice B) is indicated for choking, not for an unresponsive client. Giving rescue breaths (Choice C) is also important but only after the airway has been established.

4. A 25-year-old primigravida at 16 weeks gestation is admitted to the hospital with a diagnosis of hyperemesis gravidarum. Which nursing diagnosis should have the highest priority?

• A. Fluid volume deficit
• B. Altered nutrition: less than body requirements
• C. Anxiety related to new situational crisis
• D. Activity intolerance related to fatigue

Correct answer: A

Rationale: In a case of hyperemesis gravidarum, the priority nursing diagnosis should be addressing the Fluid volume deficit. This condition can lead to serious complications such as electrolyte imbalances and dehydration, which can endanger both the mother and the fetus if not managed promptly. Altered nutrition: less than body requirements is important but addressing the fluid volume deficit takes precedence as it poses an immediate threat. Anxiety related to new situational crisis and Activity intolerance related to fatigue are valid concerns, but they are secondary to the critical issue of fluid volume deficit in this scenario.

5. An older adult client at risk for osteoporosis is being taught by a nurse about starting a regular physical activity program. Which type of activity should the nurse recommend?

• A. Walking briskly
• B. Riding a bicycle
• C. Performing isometric exercises
• D. Engaging in high-impact aerobics

Correct answer: A

Rationale: The correct answer is walking briskly. Weight-bearing exercises, such as brisk walking, are recommended for individuals at risk for osteoporosis because they help maintain bone mass and prevent bone loss. Riding a bicycle and performing isometric exercises are not weight-bearing activities, and therefore, may not provide the same bone-strengthening benefits as walking. High-impact aerobics can increase the risk of fractures in individuals with osteoporosis due to the high level of impact involved.

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