Nursing Elites

1. A client states, 'I can leave the diaphragm in place as long as I want after intercourse.' Which statement indicates to the nurse that the client needs further information on how to use the diaphragm?

• A. 'I need to reapply spermicidal cream with repeated intercourse.'
• B. 'The diaphragm needs to be filled with spermicidal cream before insertion.'
• C. 'I can leave the diaphragm in place as long as I want after intercourse.'
• D. 'The diaphragm can be inserted as long as 6 hours before intercourse.'

Correct answer: C

Rationale: The correct answer is the statement, 'I can leave the diaphragm in place as long as I want after intercourse.' This statement indicates a lack of understanding about the correct use of the diaphragm. The diaphragm must be left in place for at least 6 hours after intercourse to ensure effectiveness and reduce the risk of pregnancy. Leaving the diaphragm in place for an extended period can lead to toxic shock syndrome. Choice A is correct as spermicidal cream needs to be reapplied before each act of intercourse for optimal contraceptive efficacy. Choice B is a correct statement as the diaphragm should be filled with spermicidal cream before insertion to increase its effectiveness. Choice D is also accurate as the diaphragm can be inserted up to 6 hours before intercourse to allow time for proper placement and effectiveness.

2. After undergoing gastric resection, the client is informed by the nurse that which of the following meals is most likely to cause rapid emptying of the stomach?

• A. a high-protein meal
• B. a high-fat meal
• C. a large meal regardless of nutrient content
• D. a high-carbohydrate meal

Correct answer: D

Rationale: After gastric resection, meals high in carbohydrates are more likely to cause rapid emptying of the stomach. Carbohydrates stimulate the release of gastrin, which accelerates gastric emptying. On the other hand, high-fat and high-protein meals tend to delay gastric emptying. A large meal, regardless of nutrient content, can also delay gastric emptying due to the increased volume of food that needs to be processed.

3. In a community hospital, a nurse is employed as a staff nurse and is supervised by a nurse manager. The nurse understands that in this position, the term authority most appropriately refers to which description?

• A. Accepting responsibility for the actions of others
• B. The official power to ensure that an organizational decision is enforced
• C. Bearing the legal responsibility for others' performance of tasks
• D. Taking responsibility for what staff members do

Correct answer: B

Rationale: The term authority refers to the official power of an individual to approve or command an action or to ensure that a decision is enforced. In the context of the nurse's position supervised by a nurse manager, having authority means having the official power to ensure that organizational decisions are carried out. Choice A, accepting responsibility for the actions of others, is more related to accountability rather than authority. Choice C, bearing the legal responsibility for others' performance of tasks, is more about legal liability rather than authority. Choice D, taking responsibility for what staff members do, is similar to choice A and is more about accountability rather than having the official power to enforce decisions. Therefore, the correct answer is B as it directly relates to the concept of authority in the context described.

4. What is the appropriate ratio of cardiac compressions to ventilations in an adult client for one-person CPR?

• A. 5:01
• B. 1:05
• C. 15:02
• D. 2:15

Correct answer: C

Rationale: The correct answer is 15:2. For one-person CPR on an adult, the ratio of compressions to ventilations is 15:2. This ratio ensures adequate oxygenation while maintaining effective circulation. Choice A (5:1) and Choice B (1:5) are incorrect ratios and do not align with the recommended guidelines for adult CPR. Choice D (2:15) is also incorrect as it reverses the order of compressions and ventilations.

5. An LPN is caring for a primarily bedridden client. Which finding should be of least concern?

• A. swollen feet
• B. brown discoloration above the ankles
• C. leg pain
• D. capillary refill time of 3 seconds on the big toe

Correct answer: D

Rationale: The correct answer is the capillary refill time of 3 seconds on the big toe. A capillary refill time longer than three seconds may indicate inadequate blood flow. Swollen feet, brown discoloration above the ankles, and leg pain are all signs of venous insufficiency to the lower extremities. These findings can suggest circulation issues and require further assessment and intervention. Therefore, they should be of more concern compared to the capillary refill time of 3 seconds on the big toe, which is within the normal range of 2-3 seconds.

Similar Questions