Nursing Elites

1. Which client is most likely to be at risk for spiritual distress?

• A. Roman Catholic woman considering an abortion
• B. Jewish man considering hospice care for his wife
• C. Seventh-day Adventist in need of a blood transfusion
• D. Muslim man in need of a total knee replacement

Correct answer: A

Rationale: The correct answer is A. In Roman Catholicism, abortion is strictly prohibited, so a Roman Catholic woman considering this procedure may experience spiritual distress due to conflicts with her religious beliefs. This conflict can lead to emotional and psychological turmoil, affecting her spiritual well-being. It is essential for healthcare providers to recognize and address such conflicts with sensitivity and understanding to provide holistic care.

2. During the digital removal of a fecal impaction, the nurse should stop the procedure and take corrective action if which client reaction is noted?

• A. Temperature increases from 98.8° to 99.0° F.
• B. Pulse rate decreases from 78 to 52 beats/min.
• C. Respiratory rate increases from 16 to 24 breaths/min.
• D. Blood pressure increases from 110/84 to 118/88 mmHg.

Correct answer: B

Rationale: During digital removal of a fecal impaction, a vagal response can occur due to stimulation of the anal sphincter. If the client experiences bradycardia (pulse rate decreases), the nurse should stop the procedure immediately and take corrective action to prevent any complications. Choices A, C, and D are incorrect because they do not indicate a vagal response, which is the expected adverse reaction during this procedure.

3. An adult has a coagulation time of 20 minutes. The nurse should observe the client for which of the following?

• A. Blood clots
• B. Ecchymotic areas
• C. Jaundice
• D. Infection

Correct answer: B

Rationale: A coagulation time of 20 minutes is prolonged, suggesting a potential bleeding disorder. Ecchymotic areas, which are areas of bruising, are common signs of abnormal bleeding. Therefore, the nurse should observe the client for ecchymotic areas to monitor for potential bleeding issues. Blood clots are not typically associated with prolonged coagulation time but rather with excessive clotting. Jaundice is related to liver dysfunction, and infection is not directly linked to coagulation time.

4. The healthcare professional counts an adult's apical heartbeat at 110 beats per minute. The healthcare professional describes this as:

• A. Asystole
• B. Bigeminy
• C. Tachycardia
• D. Bradycardia

Correct answer: C

Rationale: Tachycardia is a heart rate greater than 100 beats per minute. In this case, an adult's heart rate of 110 beats per minute falls within the range of tachycardia. Tachycardia can be a common physiological response to various stresses on the body, leading to an increased heart rate. Asystole refers to the absence of cardiac activity, bigeminy is a specific heart rhythm pattern, and bradycardia is a heart rate below 60 beats per minute in adults.

5. A client with a diagnosis of renal failure is receiving hemodialysis. Which assessment finding should the nurse report to the healthcare provider immediately?

• A. The client's blood pressure is 130/80 mm Hg.
• B. The client gains 1 kg in 24 hours.
• C. The client's potassium level is 5.5 mEq/L.
• D. The client's weight decreases by 0.5 kg in 24 hours.

Correct answer: C

Rationale: A potassium level of 5.5 mEq/L (C) is elevated and concerning in a client with renal failure receiving hemodialysis, as it can lead to life-threatening cardiac arrhythmias. Monitoring blood pressure (A), weight gain (B), and weight loss (D) are essential in clients on hemodialysis, but an elevated potassium level poses an immediate risk that requires prompt intervention.

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