Nursing Elites

1. Following a craniotomy, why did the nurse position the client in low Fowler's position?

• A. To promote comfort.
• B. To promote drainage from the operation site.
• C. To promote thoracic expansion.
• D. To prevent circulatory overload.

Correct answer: B

Rationale: Positioning the client in low Fowler's position after a craniotomy is essential to promote drainage from the operation site. This position helps prevent fluid accumulation, facilitates the removal of excess fluid or blood, and aids in the healing process. Choice A is incorrect because comfort, while important, is not the primary reason for this specific positioning. Choice C is incorrect as thoracic expansion is not the main concern following a craniotomy. Choice D is incorrect as circulatory overload is not typically addressed by positioning in low Fowler's position post-craniotomy.

2. When a health care provider diagnoses metastatic cancer and recommends a gastrostomy for an older female client in stable condition, the son tells the nurse that his mother must not be told the reason for the surgery because she 'can't handle' the cancer diagnosis. Which legal principle is the court most likely to uphold regarding this client's right to informed consent?

• A. The family cannot provide the consent required in this situation because the older adult is in a condition to make such decisions.
• B. Because the client is mentally incompetent, the son does not have the right to waive informed consent for her.
• C. The court will not allow the health care provider to make the decision to withhold informed consent under therapeutic privilege.
• D. If informed consent is withheld from a client, health care providers could be found guilty of negligence.

Correct answer: D

Rationale: In the scenario described, it is crucial for health care providers to obtain informed consent from the client before proceeding with any medical intervention. If informed consent is withheld and the treatment is carried out without the client's agreement, health care providers could be found guilty of negligence, specifically assault and battery. This legal principle emphasizes the importance of respecting a client's autonomy and right to make decisions about their own healthcare. Despite the son's wishes to withhold information from his mother, the client must be informed of the proposed treatment and given the opportunity to consent or refuse based on complete information provided by the healthcare team.

3. When assessing a client with wrist restraints, the nurse observes that the fingers on the right hand are blue. What action should the nurse implement first?

• A. Loosen the right wrist restraint.
• B. Apply a pulse oximeter to the right hand.
• C. Compare hand color bilaterally.
• D. Palpate the right radial pulse.

Correct answer: A

Rationale: The priority nursing action is to restore circulation by loosening the restraint (A) because blue fingers (cyanosis) indicate decreased circulation. Comparing hand color bilaterally (C) and palpating the right radial pulse (D) are important assessments to gather more information, but they do not have the priority of addressing the decreased circulation by loosening the restraint. Applying a pulse oximeter (B) is not indicated in this scenario as it measures the saturation of hemoglobin with oxygen, which is not relevant when cyanosis is related to mechanical compression from the restraints.

4. What assessment finding places a client at risk for problems associated with impaired skin integrity?

• A. Scattered macules on the face
• B. Capillary refill of 5 seconds
• C. Smooth nail texture
• D. Presence of skin tenting

Correct answer: B

Rationale: The correct answer is B. A capillary refill time greater than 3 seconds indicates poor perfusion, leading to impaired skin integrity. Delayed capillary refill can compromise blood flow to the skin, increasing the risk of pressure ulcers or wounds due to reduced tissue perfusion. Choices A, C, and D are incorrect because scattered macules on the face, smooth nail texture, and presence of skin tenting are not direct indicators of impaired skin integrity or risk for skin problems.

5. While suctioning a client’s nasopharynx, the nurse observes that the client’s oxygen saturation remains at 94%, which is the same reading obtained prior to starting the procedure. What action should the nurse take in response to this finding?

• A. Complete the intermittent suction of the nasopharynx.
• B. Reposition the pulse oximeter clip to obtain a new reading.
• C. Stop suctioning until the pulse oximeter reading is above 95%.
• D. Apply an oxygen mask over the client’s nose and mouth.

Correct answer: A

Rationale: A stable oxygen saturation reading of 94% indicates that the nurse can continue with the suctioning procedure. It is within an acceptable range, and there is no immediate need to interrupt the procedure. Continuing with the suctioning will help maintain airway patency and promote adequate oxygenation. Choice B is incorrect because repositioning the pulse oximeter clip is unnecessary when the reading is stable. Choice C is incorrect as there is no evidence to support stopping the suctioning procedure solely based on the oxygen saturation reading of 94%. Choice D is not the best action at this point, as applying an oxygen mask is not indicated when the oxygen saturation is stable and within an acceptable range.

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