Nursing Elites

1. Which nonverbal action should be implemented to demonstrate active listening?

• A. Sit facing the individual.
• B. Cross arms and legs.
• C. Avoid eye contact.
• D. Lean back in the chair.

Correct answer: A

Rationale: To demonstrate active listening effectively, it is essential to display open and engaging body language. Sitting facing the individual helps convey attentiveness and a willingness to listen. Maintaining eye contact further enhances the connection and shows respect and interest in the conversation. Crossing arms and legs can create a barrier and signal defensiveness or disinterest. Avoiding eye contact may suggest a lack of engagement or attentiveness. Leaning back in the chair can indicate relaxation but might be perceived as disengagement. Therefore, the most appropriate nonverbal action to demonstrate active listening is to sit facing the individual and maintain eye contact.

2. Before administering a client's medication, the nurse assesses a change in the client's condition and decides to withhold the medication until consulting with the healthcare provider. After consultation with the healthcare provider, the dose of the medication is changed, and the nurse administers the newly prescribed dose an hour later than the originally scheduled time. What action should the nurse take in response to this situation?

• A. Notify the charge nurse that a medication error occurred.
• B. Submit a medication variance report to the supervisor.
• C. Document the events that occurred in the nurse's notes.
• D. Discard the original medication administration record.

Correct answer: C

Rationale: In this scenario, the nurse acted appropriately by withholding the medication, consulting with the healthcare provider, and administering the newly prescribed dose, albeit with a delay. The correct course of action for the nurse is to document all these events in the nurse's notes. Documenting the sequence of actions taken is crucial for maintaining an accurate record of the client's care, ensuring transparency, and providing essential information for future reference and continuity of care. Notifying the charge nurse or submitting a medication variance report may not be necessary as the situation was managed appropriately, and discarding the original medication administration record is not recommended as it is part of the client's medical record and should be kept for documentation purposes.

3. The client with chronic obstructive pulmonary disease (COPD) is receiving oxygen therapy. Which intervention should the nurse implement to ensure the client’s safety?

• A. Encourage the client to use oxygen continuously
• B. Monitor the client’s respiratory rate and effort
• C. Set the oxygen flow rate at 6 liters per minute
• D. Teach the client to avoid wearing wool blankets

Correct answer: B

Rationale: Monitoring the client’s respiratory rate and effort is essential to evaluate the effectiveness of oxygen therapy and prevent complications such as respiratory depression. This intervention helps the nurse promptly detect any deterioration in the client's respiratory status and take necessary actions to ensure the client's safety. Encouraging continuous oxygen use (Choice A) may lead to oxygen toxicity. Setting the oxygen flow rate at a specific level (Choice C) without individual assessment can be inappropriate and potentially harmful. Teaching the client to avoid wearing wool blankets (Choice D) is unrelated to the safe use of oxygen therapy.

4. When planning care for a client with an indwelling urinary catheter, which nursing diagnosis has the highest priority?

• A. Self-care deficit
• B. Functional incontinence
• C. Fluid volume deficit
• D. High risk for infection

Correct answer: D

Rationale: The highest priority nursing diagnosis when planning care for a client with an indwelling urinary catheter is 'High risk for infection.' Indwelling urinary catheters pose a significant risk of infection due to their direct contact with the urinary system. Preventing and managing infections is crucial in the care of these clients. Monitoring for signs of infection, following proper catheter care protocols, and maintaining aseptic technique during catheter maintenance are essential steps to prevent complications associated with catheter-related infections. Choices A, B, and C are not the highest priority because in this case, the immediate concern is the risk of infection associated with the presence of the urinary catheter. While self-care deficit, functional incontinence, and fluid volume deficit are important considerations in overall patient care, they are not as critical as preventing potentially serious infections related to the indwelling urinary catheter.

5. An older client who had abdominal surgery 3 days earlier was given a barbiturate for sleep and is now requesting to go to the bathroom. Which action should the nurse implement?

• A. Assist the client to walk to the bathroom and do not leave the client alone.
• B. Request that the UAP assist the client onto a bedpan.
• C. Ask if the client needs to have a bowel movement or void.
• D. Assess the client's bladder to determine if the client needs to urinate.

Correct answer: A

Rationale: Barbiturates cause central nervous system (CNS) depression, increasing the risk of falls. It is crucial for the nurse to assist the client to the bathroom to prevent potential injuries. Leaving the client alone may lead to accidents due to the effects of the medication. Monitoring and supporting the client during this activity is essential for ensuring safety and preventing falls.

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