Nursing Elites

1. A 54-year-old male client and his wife were informed this morning that he has terminal cancer. Which nursing intervention is likely to be most beneficial?

• A. Ask the wife how she would like to participate in the client’s care.
• B. Provide the wife with information about hospice.
• C. Encourage the wife to visit during and after painful treatments are completed.
• D. Refer the wife to a support group for family members of those dying of cancer.

Correct answer: A

Rationale: During this challenging time of dealing with a terminal cancer diagnosis, involving the wife in the care process can be highly beneficial. By asking the wife how she would like to participate in the client’s care, it allows her to feel more in control and connected. This approach fosters a collaborative care environment, ensuring that the wife's preferences and needs are taken into consideration. Providing information about hospice (choice B) may be premature at this stage and could potentially overwhelm the family. Encouraging the wife to visit during and after painful treatments (choice C) may not address her need for involvement in decision-making. Referring the wife to a support group (choice D) is helpful but may not directly involve her in the care process of her husband.

2. 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.

3. What is the most important instruction for the nurse to provide a client with a new colostomy regarding stoma care?

• A. Cleanse the stoma with hydrogen peroxide and water.
• B. Apply a moisture barrier cream to the peristomal skin.
• C. Measure the stoma using a stoma guide.
• D. Use a dry gauze pad to clean the stoma.

Correct answer: C

Rationale: Measuring the stoma using a stoma guide (C) is crucial as it ensures that the appliance fits properly, which is essential for preventing skin irritation and leakage. Proper measurement helps in selecting the right size of the appliance, promoting comfort and optimal stoma care. In contrast, cleansing with hydrogen peroxide (A), applying a moisture barrier cream (B), and using a dry gauze pad (D) are important but not as critical as ensuring the correct fit of the stoma appliance.

4. After a needle stick occurs while removing the cap from a sterile needle, what action should the individual take?

• A. Complete an incident report.
• B. Select another sterile needle.
• C. Disinfect the needle with an alcohol swab.
• D. Notify the supervisor immediately.

Correct answer: B

Rationale: In the scenario described, the correct action after a needle stick injury is to discard the contaminated needle safely and choose a new sterile needle to continue the procedure. This step helps prevent potential transmission of infections and ensures the safety of both the individual and the patient. Disinfecting the needle with an alcohol swab is not adequate to address the risk of infection transmission. While completing an incident report and notifying the supervisor are important, the immediate action should be to replace the contaminated needle with a new sterile one to prevent any potential harm.

5. When turning an immobile bedridden client without assistance, which action best ensures client safety?

• A. Securely grasp the client's arm and leg.
• B. Put bed rails up on the side of bed opposite from the nurse.
• C. Correctly position and use a turn sheet.
• D. Lower the head of the client's bed slowly.

Correct answer: B

Rationale: The correct answer is to put bed rails up on the side of the bed opposite from the nurse. This action is essential to prevent the client from falling out of bed during the turning process. Since the nurse can only stand on one side of the bed, having the bed rails up on the opposite side provides an additional safety measure. Securing the client's arm and leg or lowering the head of the bed would not prevent the client from falling and may pose a risk of injury. Using a turn sheet correctly can be helpful, but ensuring the bed rails are up is a more direct safety measure in this situation.

Similar Questions