Nursing Elites

1. On admission to the psychiatric unit, the client is trembling and appears fearful. The nurse’s initial response should be to

• A. Give the client orientation materials and review the unit rules and regulations
• B. Introduce oneself and accompany the client to their room
• C. Take the client to the day room and introduce them to the other clients
• D. Ask the nursing assistant to get the client’s vital signs and complete the admission search

Correct answer: B

Rationale: In situations where a client is trembling and fearful upon admission to a psychiatric unit, it is essential to prioritize building trust and reducing anxiety. By introducing oneself and accompanying the client to their room, the nurse can establish a therapeutic relationship, provide a sense of security, and address the client's immediate emotional needs. Choices A, C, and D are not the most appropriate initial responses as they do not directly address the client's emotional state or focus on establishing a supportive relationship.

2. A client with a peptic ulcer is scheduled for a vagotomy and pyloroplasty. The nurse explains that the purpose of this surgery is to:

• A. Increase acid secretion
• B. Reduce acid secretion
• C. Promote gastric emptying
• D. Remove the ulcerated area

Correct answer: B

Rationale: The correct answer is B: "Reduce acid secretion." Vagotomy is performed to reduce acid secretion by cutting the vagus nerve, which stimulates acid production. Choices A, C, and D are incorrect. A vagotomy does not increase acid secretion, promote gastric emptying, or remove the ulcerated area. It specifically aims to decrease acid production to help in the healing of peptic ulcers.

3. Which statement specifically describes occupational health nursing?

• A. Involves prevention, recognition, and treatment of injury and illness
• B. All of these
• C. The application of nursing principles in conserving the health of workers in all occupations
• D. Requires special skills in the field of health, education, and counseling

Correct answer: B

Rationale: The correct answer is B. Occupational health nursing involves all aspects mentioned in the statements: prevention, recognition, treatment of injury and illness, application of nursing principles in conserving workers' health, and the requirement of special skills in health, education, and counseling. Choice A focuses on prevention, recognition, and treatment but does not encompass all aspects of occupational health nursing. Choice C only mentions the application of nursing principles without including prevention and treatment. Choice D specifically highlights the need for special skills but does not cover all the aspects of occupational health nursing.

4. The RN is making a home visit to a female client with end-stage heart disease. She has a living will and states she will never go back to the hospital. During the visit, the RN notes that the client is pale and SOB while speaking. The RN discovers 3+ edema in both ankles and bilateral pulmonary crackles. Which intervention should the RN implement first?

• A. Order a chest X-ray
• B. Obtain a peripheral O2 saturation reading
• C. Obtain an order for complete blood count
• D. Tell the patient to stay in bed

Correct answer: B

Rationale: Obtaining a peripheral O2 saturation reading is the priority intervention in this scenario. It helps assess the client's oxygenation status quickly, which is crucial in a client with signs of respiratory distress, such as shortness of breath and bilateral pulmonary crackles. Ordering a chest X-ray (Choice A) may be necessary later but does not address the immediate need for oxygen assessment. Obtaining an order for a complete blood count (Choice C) is not the priority in this situation as it does not directly address the client's respiratory distress. Instructing the patient to stay in bed (Choice D) does not address the underlying issue of potential hypoxia and respiratory compromise.

5. The new graduate nurse interviews for a position in a nursing department of a large health care agency, described by the interviewer as having shared governance. Which of these statements best illustrates the shared governance model?

• A. An appointed board oversees any administrative decisions
• B. Nursing departments share responsibility for client outcomes
• C. Staff groups are appointed to discuss nursing practice and client education issues
• D. Non-nurse managers supervise nursing staff in groups of units

Correct answer: B

Rationale: The correct answer is B because shared governance involves nurses and other staff sharing responsibility for decisions related to patient care and outcomes, promoting collaborative practice and shared accountability. Choice A is incorrect as shared governance includes active participation of frontline staff, not just an appointed board. Choice C is incorrect because shared governance goes beyond just discussing issues to actively sharing responsibility for decision-making. Choice D is incorrect as shared governance encourages nurses to have a significant role in decision-making rather than being supervised by non-nurse managers.

Similar Questions