Nursing Elites

1. The daughter of an older woman who became depressed following the death of her husband asks, 'My mother was always well-adjusted until my father died. Will she tend to be sick from now on?' Which response is best for the nurse to provide?

• A. She is almost sure to be less able to adapt than before.
• B. It's highly likely that she will recover and return to her pre-illness state.
• C. If you can interest her in something besides religion, it will help her stay well.
• D. Cultural strains contribute to each woman's tendencies for recurrences of depression.

Correct answer: B

Rationale: The successful resolution of a developmental crisis in the later years involves acceptance and adaptation, and the daughter should be reassured that recovery is likely.

2. When caring for a client with a chest tube, which intervention is most important?

• A. Keep the drainage system at chest level.
• B. Ensure that the chest tube is clamped at all times.
• C. Strip the chest tube every shift.
• D. Ensure that the chest tube is connected to a water-seal drainage system.

Correct answer: D

Rationale: The most crucial intervention when caring for a client with a chest tube is to ensure that the chest tube is connected to a water-seal drainage system (D). This system helps maintain proper lung expansion and prevents complications. Keeping the drainage system at chest level (A) is important to facilitate drainage, but not as critical as ensuring the connection to the drainage system. Clamping the chest tube (B) is unnecessary and can lead to serious issues. Stripping the chest tube (C) is an outdated practice and can cause harm rather than benefit.

3. A client has an elevated AST 24 hours following chest pain and shortness of breath. This is suggestive of which of the following?

• A. Gallbladder disease
• B. Liver disease
• C. Myocardial infarction
• D. Skeletal muscle injury

Correct answer: C

Rationale: An elevated AST level following chest pain and shortness of breath is suggestive of myocardial infarction. AST is released from damaged heart muscle cells during a heart attack, indicating cardiac involvement. This enzyme is not specific to liver disease, gallbladder disease, or skeletal muscle injury in this clinical context.

4. Which intervention is most important to include in the plan of care for a client at high risk for the development of postoperative thrombus formation?

• A. Instruct the client in the use of the incentive spirometer.
• B. Elevate the head of the bed during all meals.
• C. Use aseptic technique when changing the dressing.
• D. Encourage frequent ambulation in the hallway.

Correct answer: D

Rationale: Thrombus formation is a risk for clients who are immobile postoperatively. Encouraging frequent ambulation helps to prevent stasis in the lower extremities, reducing the risk of thrombus formation. This intervention promotes circulation and prevents blood clot formation, making it the most important intervention in this situation.

5. After receiving written and verbal instructions from a clinic nurse about a newly prescribed medication, a client asks the nurse what to do if questions arise about the medication after getting home. How should the nurse respond?

• A. Provide the client with a list of reputable Internet sites that answer frequently asked questions about medications.
• B. Advise the client to obtain a current edition of a drug reference book from a local bookstore or library.
• C. Reassure the client that information about the medication is included in the written instructions.
• D. Encourage the client to call the clinic nurse or health care provider if any questions arise.

Correct answer: D

Rationale: To ensure safe medication use, the nurse should encourage the client to call the clinic nurse or health care provider if any questions arise. Direct communication with healthcare professionals involved in the client's care is crucial to address any concerns promptly and accurately, ensuring the client's safety and understanding of the prescribed medication.

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