Nursing Elites

1. During the admission interview, an older client answers some questions inappropriately. The nurse notes that a hearing aid is in one ear. Which intervention is most helpful in assisting the client to hear the nurse’s question?

• A. Move to the client's other side.
• B. Speak louder into the client's ear with the hearing aid.
• C. Ask the client to adjust the hearing aid volume.
• D. Restate questions articulating consonants carefully.

Correct answer: D

Rationale: Restating questions with clear articulation is the most helpful intervention in assisting the client to hear the nurse's question. This approach ensures that the client can better understand the question, especially if there are issues with the hearing aid. Moving to the client's other side or speaking louder into the ear with the hearing aid may not effectively address the problem of clarity in communication. Asking the client to adjust the hearing aid volume assumes that the issue lies solely with the volume, while restating questions with clear articulation can help overcome various hearing difficulties.

2. The client with chronic venous insufficiency is being taught about self-care measures. Which instruction should be included?

• A. Avoid wearing compression stockings
• B. Elevate legs above heart level when resting
• C. Apply heat packs to improve circulation
• D. Limit walking to prevent leg pain

Correct answer: B

Rationale: The correct instruction for a client with chronic venous insufficiency is to elevate their legs above heart level when resting. This position helps reduce venous pressure and edema, improving circulation. Avoiding compression stockings (choice A) is incorrect as they are beneficial in managing chronic venous insufficiency. Applying heat packs (choice C) is not recommended as heat can worsen edema. Limiting walking (choice D) is not advisable as regular, gentle exercise like walking can actually help improve circulation in patients with chronic venous insufficiency.

3. A young adult male is admitted to the intensive care unit with multiple rib fractures and severe pulmonary contusions after falling 20 feet from a rooftop. The Chest X-ray suggests acute Respiratory distress Syndrome. Which assessment finding warrants immediate intervention by the Nurse?

• A. Apical pulse 58 bpm.
• B. Core body temperature 100.8°F.
• C. Tachypnea with dyspnea.
• D. Multiple bruises over the chest area.

Correct answer: C

Rationale: In a patient with multiple rib fractures, severe pulmonary contusions, and possible acute Respiratory Distress Syndrome (ARDS), tachypnea (rapid breathing) with dyspnea (shortness of breath) is a critical sign of respiratory distress that warrants immediate intervention by the nurse. Tachypnea and dyspnea indicate inadequate oxygenation and ventilation, which can lead to respiratory failure if not addressed promptly. The other options, such as apical pulse rate, core body temperature, and bruises over the chest area, are important assessments but do not directly indicate the immediate need for intervention in a patient with respiratory distress.

4. A client with Cushing's Syndrome is recovering from an elective laparoscopic procedure. Which assessment finding warrants immediate intervention by the nurse?

• A. Irregular apical pulse
• B. Purple marks on the skin of the abdomen
• C. Quarter-sized blood spot on the dressing
• D. Pitting ankle edema

Correct answer: A

Rationale: The correct answer is A: Irregular apical pulse. In a client recovering from a laparoscopic procedure with Cushing's Syndrome, an irregular apical pulse can be indicative of a life-threatening arrhythmia and requires immediate intervention. Choices B, C, and D are not as urgent as an irregular apical pulse. Purple marks on the skin of the abdomen may be related to Cushing's Syndrome, a quarter-sized blood spot on the dressing can be managed with appropriate wound care, and pitting ankle edema may be expected postoperatively but does not require immediate intervention.

5. A client who was discharged 8 months ago with cirrhosis and ascites is admitted with anorexia and recent hemoptysis. The client is drowsy but responds to verbal stimuli. The nurse programs a blood pressure monitor to take readings every 15 minutes. Which assessment should the nurse implement first?

• A. Evaluate distal capillary refill for delayed perfusion
• B. Check the extremities for bruising and petechiae
• C. Examine the peritibial regions for pitting edema
• D. Palpate the abdomen for tenderness and rigidity

Correct answer: D

Rationale: In a client with a history of cirrhosis and ascites presenting with anorexia and recent hemoptysis, palpating the abdomen for tenderness and rigidity is crucial as it helps in identifying signs of complications related to these conditions. Assessing for abdominal tenderness and rigidity can provide valuable information about the presence of internal bleeding, ascites complications, or liver enlargement. Evaluating distal capillary refill, checking for bruising and petechiae, or examining peritibial regions for pitting edema are important assessments but are not the priority in this case, given the client's history and current symptoms.

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