Nursing Elites

1. A nursing care plan for a client with sleep problems has been implemented. All of the following should be expected outcomes except:

• A. the client reports no episodes of awakening during the night.
• B. the client falls asleep within 1 hour of going to bed.
• C. the client reports satisfaction with their amount of sleep.
• D. the client rates sleep as an 8 or more on the visual analog scale.

Correct answer: B

Rationale: An expected outcome for a nursing care plan targeting sleep problems is that the client reports no episodes of awakening during the night, the client reports satisfaction with their amount of sleep, and the client rates sleep as an 8 or more on the visual analog scale. Falling asleep within 1 hour of going to bed is not necessarily an expected outcome. While it is generally desirable for individuals to fall asleep within a reasonable time frame, this specific timeframe may vary among individuals, and it is not a strict criterion for successful sleep outcomes. Therefore, the correct answer is that the client falls asleep within 1 hour of going to bed, as this is not a definitive measure of the effectiveness of the nursing care plan for sleep problems.

2. A nurse in a medical-surgical unit overhears the nursing staff openly discussing a client and stating that the client is uncooperative and a real pain to care for. The nurse would most appropriately manage this issue by taking which action?

• A. Leaving articles about judgmental opinions in the nurses' report room
• B. Reporting the nurses' comments to administration
• C. Discouraging the judgmental comments
• D. Ignoring the comments made about the client

Correct answer: C

Rationale: Nurses must discuss clients in a professional manner and avoid using judgmental language such as 'uncooperative' or 'difficult.' When such comments and language are discouraged, fewer comments will be made. Ignoring the comments is an inappropriate option because the concern will not be addressed. Leaving articles about judgmental opinions in the nurses' report room indirectly addresses the issue, but there is no guarantee that the staff will read them. Reporting the nurses' comments to administration does not directly address the issue. The best approach for the nurse is to discourage judgmental comments directly with the staff members. Since this action is not provided in the options, discouraging judgmental comments is the most appropriate way to manage this concern.

3. A nurse on the night shift is making client rounds. When the nurse checks a client who is 97 years old and has successfully been treated for heart failure, he notes that the client is not breathing. If the client does not have a do-not-resuscitate (DNR) order, the nurse should take which action?

• A. Administer cardiopulmonary resuscitation (CPR)
• B. Call the client's health care provider
• C. Administer oxygen to the client and call the health care provider
• D. Contact the nursing supervisor for directions

Correct answer: A

Rationale: Administering cardiopulmonary resuscitation (CPR) is the appropriate action when a client is not breathing and does not have a do-not-resuscitate (DNR) order. CPR is considered an emergency treatment that can be provided without client consent in life-threatening situations. Calling the health care provider or nursing supervisor for directions, as well as administering oxygen without addressing the lack of breathing, would delay critical life-saving interventions. Therefore, administering CPR is the most urgent and necessary action to perform in this scenario.

4. A nurse is preparing for the admission of a client with pulmonary tuberculosis. Which action reflects the use of evidence-based practice in the care of the client?

• A. Keeping the door to the client's room closed
• B. Fitting the client for an N95 or HEPA (high-efficiency particulate air) mask to be worn at all times
• C. Placing the client in a semiprivate room with a cohort client
• D. Using a surgical mask when entering the client's room

Correct answer: A

Rationale: Evidence-based practice is an approach to client care that integrates the client's preferences, clinical expertise, and the best research evidence to deliver quality care. In the case of pulmonary tuberculosis, which is transmitted through the airborne route, keeping the door to the client's room closed is crucial to prevent the spread of infection. Placing the client in a semiprivate room with a cohort client is not recommended for airborne precautions; a private room is required to prevent transmission. Fitting the client for an N95 or HEPA mask is essential for the nurse's protection when entering the room, not for the client to wear at all times. Using a surgical mask when entering the client's room is not sufficient for airborne precautions; an N95 or HEPA mask is necessary.

5. When ambulating a client with right-sided weakness, a nursing assistant should be positioned on which side of the client?

• A. Stands behind the client
• B. Positions the free hand on the client's shoulder
• C. Stands on the right side of the client
• D. Grasps the security belt in the midspine area of the small of the client's back

Correct answer: C

Rationale: When ambulating a client with right-sided weakness, the nursing assistant should stand on the affected side, which in this case is the client's right side. This position allows the assistant to provide proper support and assistance. Standing behind the client (Choice A) is incorrect as the assistant should be on the affected side. Positioning the free hand on the client's shoulder (Choice B) is a correct action as it helps in pulling the client toward them in case of a forward fall. Grasping the security belt in the midspine area of the small of the client's back (Choice D) is also correct to provide support and stability during ambulation.

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