Nursing Elites

1. In a group therapy setting, one member is very demanding, repeatedly interrupting others and taking most of the group time. The nurse's best response would be:

• A. Will you briefly summarize your point because others need time as well?
• B. Your behavior is obnoxious and drains the group.
• C. I am so frustrated with your behavior.
• D. To ignore the behavior and allow him to vent

Correct answer: A

Rationale: In a group therapy setting, where each member should have the opportunity to participate, it is essential for the nurse to manage disruptive behavior assertively yet respectfully. Choice A is the best response as it addresses the issue of one member dominating the group time by asking them to summarize their point briefly, allowing others to contribute. Choice B is confrontational and may alienate the individual, hindering the therapeutic process. Choice C expresses personal frustration, which is not constructive in managing the situation. Choice D of ignoring the behavior is not effective as it allows the disruptive behavior to continue, impacting the group dynamics negatively.

2. A client on bedrest refuses to wear the prescribed pneumatic compression devices after surgery. Which action should the PN implement in response to the client's refusal?

• A. Emphasize the importance of active foot flexion
• B. Check the surgical dressing
• C. Complete an incident report
• D. Explain the use of an incentive spirometer every 2 hours

Correct answer: A

Rationale: The correct action for the PN to implement when a client refuses pneumatic compression devices is to emphasize the importance of active foot flexion. Active foot flexion exercises can help prevent deep vein thrombosis (DVT) in clients who are not using the compression devices. Encouraging some form of circulation-promoting activity is crucial to reduce the risks associated with immobility. Checking the surgical dressing (Choice B) is important but not the immediate action to address the refusal of compression devices. Completing an incident report (Choice C) is not necessary in this situation as the client's refusal is not an incident. Explaining the use of an incentive spirometer (Choice D) is not directly related to addressing the refusal of compression devices for DVT prevention.

3. A nurse is assessing a day-old infant for jaundice. Which of the following is the best method for this?

• A. Applying pressure over a bony area such as the forehead and evaluating the skin color after the pressure is removed
• B. Assessing the color of the infant’s hands and feet
• C. Assessing the infant’s tongue
• D. Assessing the infant’s arms and legs

Correct answer: A

Rationale: The correct answer is A. Applying pressure over a bony area and evaluating the skin color after the pressure is removed is the most accurate method for assessing jaundice in a day-old infant. This technique helps in identifying any yellowing of the skin, which is a key indicator of jaundice. Choices B, C, and D are less effective methods for assessing jaundice in a newborn. Assessing the color of the hands and feet may not give a reliable indication of jaundice, while evaluating the tongue, arms, and legs are not as specific or accurate as applying pressure over a bony area.

4. A client with a chest tube following a pneumothorax is concerned about the continuous bubbling in the water seal chamber. What should the nurse explain to the client?

• A. Continuous bubbling in the water seal chamber indicates an air leak.
• B. Continuous bubbling is normal and expected with a chest tube.
• C. Bubbling will stop when the lung has fully expanded.
• D. The nurse should notify the healthcare provider immediately.

Correct answer: A

Rationale: Continuous bubbling in the water seal chamber of a chest tube system indicates an air leak. An air leak can prevent the lung from fully re-expanding and may lead to complications like a recurrent pneumothorax. Therefore, it is crucial to investigate and address the air leak promptly. Choices B and C are incorrect because continuous bubbling is not normal and does not indicate lung expansion. Choice D is incorrect because the nurse should first assess and then report the issue to the healthcare provider.

5. The nurse is preparing to provide wound care for a client. Which step should be done first?

• A. Don procedural gloves
• B. Remove the dressing
• C. Apply prescribed medications to the wound
• D. Don a pair of sterile gloves

Correct answer: A

Rationale: The correct answer is to don procedural gloves first. Donning procedural gloves is essential to protect the nurse from contaminants while removing the old dressing. This step helps maintain aseptic technique and prevents the transfer of microorganisms. Removing the dressing (choice B) should follow after wearing gloves to prevent the spread of pathogens. Applying prescribed medications (choice C) should be done after the wound is cleaned and dressed. Donning a pair of sterile gloves (choice D) is not necessary for initial wound care; procedural gloves are sufficient for standard wound care.

Similar Questions