Nursing Elites

1. The nurse is caring for a postpartum woman who has relinquished her baby for adoption. The care plan for the client should include which of the following priority strategies?

• A. Make a referral for grief counseling.
• B. Allow the woman to see her baby initially and respect her wishes for further visits.
• C. Provide opportunities for the woman to express her feelings.
• D. Inform the woman she has the right to change her mind about relinquishment.

Correct answer: C

Rationale: When caring for a postpartum woman who has relinquished her baby for adoption, it is crucial for the nurse to provide opportunities for the woman to express her feelings. Most women who make this decision have done so with love and pain, and it is essential to allow them to verbalize their emotions, which may include grief, loneliness, and guilt. Referring the woman for grief counseling may be necessary if she lacks a support system or requests help to navigate her grief. Allowing the woman to see her baby is important, and the nurse should respect her wishes regarding visitation as it can aid in the grief process. While the woman does have the right to change her mind about relinquishment until final legal arrangements are made, suggesting this option may inadvertently influence her decision and should be approached cautiously. Therefore, providing emotional support and opportunities for expression are the priority strategies in this situation.

2. When caring for a patient who is hard-of-hearing, which of the following steps may be appropriate when communicating with the patient?

• A. Divide the verbal communication into smaller sections and address one at a time.
• B. Communicate only with written information.
• C. Ask multiple questions in a row quickly to make sure the patient is remaining engaged.
• D. Frequently communicate without assistive devices to help the patient improve their hearing.

Correct answer: A

Rationale: When caring for a patient who is hard-of-hearing, it is important to divide verbal communication into smaller sections and address them one at a time. This approach helps the patient follow along more easily and understand the information being conveyed. While using written information can also be beneficial, solely relying on written communication may not always be practical or feasible for effective interaction. Asking multiple questions quickly can overwhelm the patient and hinder their ability to process each question adequately. It is essential to give the patient sufficient time to comprehend and respond. Additionally, frequently communicating without assistive devices is not recommended. Using assistive devices can significantly enhance the patient's ability to hear and understand, promoting better communication and patient care.

3. The physician orders the antibiotics ampicillin (Omnipen) and gentamicin (Garamycin) for a newly admitted client with an infection. The nurse should:

• A. administer both medications simultaneously
• B. give the medications sequentially, and flush well between them
• C. ask the physician or pharmacy which medication to give first and how long to wait before giving the other drug
• D. start one medication now and begin the other medication in 2-4 hours

Correct answer: B

Rationale: The correct answer is to give the medications sequentially and flush well between them. Ampicillin has a pH of 8-10, while gentamicin has a pH of 3-5.5, making them incompatible when given together. Flushing well between drugs is necessary to prevent any potential interactions. Option A is incorrect because administering both medications simultaneously can lead to incompatibility issues. Option C is incorrect because the nurse should already be aware of the correct administration sequence and not need to consult the physician or pharmacy each time. Option D is incorrect because delaying the second medication by several hours can slow down the treatment of the client's infection, which is not ideal in this scenario.

4. When removing hard contact lenses from an unresponsive client, what should the nurse do?

• A. Gently irrigate the eye with an irrigating solution from the inner canthus outward.
• B. Grasp the lens with a gentle pinching motion.
• C. Don sterile gloves before attempting the procedure.
• D. Ensure that the lens is centered on the cornea before gently manipulating the lids to release the lens.

Correct answer: D

Rationale: When removing hard contact lenses, it is crucial to ensure that the lens is correctly positioned on the cornea before removal. Directly grasping the lens can potentially scratch the cornea, so it is essential to gently manipulate the lids to release the lens safely. Gently irrigating the eye is unnecessary and could be harmful, especially without the client's cooperation. Wearing sterile gloves is also unnecessary for this specific procedure. Therefore, the correct approach is to ensure the proper positioning of the lens and then gently manipulate the lids to release it. Options A and C are incorrect because irrigating the eye and wearing sterile gloves are not necessary for contact lens removal. Option B is incorrect as directly grasping the lens can be harmful to the cornea.

5. What is most likely to impact the body image of an infant newly diagnosed with Hemophilia?

• A. immobility
• B. altered growth and development
• C. hemarthrosis
• D. altered family processes

Correct answer: D

Rationale: Altered Family Processes play a significant role in impacting the body image of an infant newly diagnosed with Hemophilia. Infants are highly perceptive of their caregivers' responses, and any changes in family dynamics due to the diagnosis can affect the infant's sense of security and trust, influencing their body image and self-perception. Immobility, while a long-term effect of hemophilia, is not an immediate impact on body image. Altered growth and development would not have manifested immediately post-diagnosis. Hemarthrosis, characterized by bleeding into joint spaces, is a hallmark of hemophilia but does not directly influence body image in the immediate aftermath of a new diagnosis.

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