Nursing Elites

1. A client in a long-term care facility reports to the nurse that he has not had a bowel movement in 2 days. Which intervention should the nurse implement first?

• A. Instruct the caregiver to offer a glass of warm prune juice at mealtimes.
• B. Notify the healthcare provider and request a prescription for a large-volume enema.
• C. Assess the client's medical record to determine the client's normal bowel pattern.
• D. Instruct the caregiver to increase the client's fluids to five 8-ounce glasses per day.

Correct answer: C

Rationale: When a client reports a change in bowel habits, the first step for the nurse is to assess the client's normal bowel pattern by reviewing the medical records. This assessment helps the nurse understand the client's baseline, which is crucial before initiating any interventions. By determining the client's usual bowel habits, the nurse can identify deviations from the norm and make informed decisions on the appropriate course of action. Assessing the client's medical record is a critical first step in addressing the client's bowel concerns. Choices A, B, and D are incorrect because they jump to interventions without first establishing the client's normal bowel pattern. Offering warm prune juice, requesting a large-volume enema, or increasing fluids may not be appropriate until the nurse knows the client's regular bowel habits and can assess the situation effectively.

2. A community hospital is opening a mental health services department. Which document should the nurse use to develop the unit's nursing guidelines?

• A. Americans with Disabilities Act of 1990
• B. ANA Code of Ethics with Interpretative Statements
• C. ANA's Scope and Standards of Nursing Practice
• D. Patient's Bill of Rights of 1990

Correct answer: C

Rationale: The ANA's Scope and Standards of Nursing Practice are essential guidelines for nursing practice in various specialties, including mental health. The document outlines the expectations and responsibilities of nurses in providing high-quality care within their specific practice areas. In the context of opening a mental health services department, using the Scope and Standards specific to psychiatric–mental health nursing would ensure that the unit's nursing guidelines align with best practices and professional standards in mental health care. Choices A, B, and D are not focused on providing specific guidelines for nursing practice in a mental health services department, making them incorrect options.

3. The client reports still being unable to sleep a week after learning progressive muscle relaxation techniques. Which action should the nurse take first?

• A. Instruct the client to add regular exercise to the daily routine.
• B. Determine if the client has been keeping a sleep diary.
• C. Encourage the client to continue the routine until sleep is achieved.
• D. Ask the client to describe the routine currently followed.

Correct answer: D

Rationale: The nurse should first assess the client's adherence to the original instructions. By asking the client to describe the routine, the nurse can evaluate if the technique is being correctly implemented before considering further interventions. This choice is correct as it focuses on assessing the client's current practice. Option A is incorrect as adding regular exercise may not address the issue with the relaxation technique. Option B is incorrect as determining if the client has been keeping a sleep diary does not directly address the efficacy of the relaxation technique. Option C is incorrect as blindly encouraging the client to continue may not be the best approach without understanding how the technique is being practiced.

4. To avoid nerve injury, what location should the nurse select to administer a 3 mL IM injection?

• A. Ventrogluteal
• B. Outer upper quadrant of the buttock
• C. Two inches below the acromion process
• D. Vastus lateralis

Correct answer: A

Rationale: The ventrogluteal site is the preferred location for administering large volume IM injections to avoid nerve injury. This site is situated away from major nerves and blood vessels, reducing the risk of complications associated with injecting into other areas. The ventrogluteal site allows for deep muscle penetration and is recommended for injections over 2 mL in volume to ensure proper dispersion and absorption of the medication. Choices B, C, and D are incorrect because the outer upper quadrant of the buttock is not the recommended site for large volume injections, two inches below the acromion process is a location for a deltoid injection, and the vastus lateralis is typically used for smaller volume injections.

5. A female UAP is assigned to take the vital signs of a client with pertussis for whom droplet precautions have been implemented. The UAP requests a change in assignment because she has not yet been fitted for a particulate filter mask. Which action should the nurse take?

• A. Advise the UAP to wear a standard face mask to take vital signs and then get fitted for a filter mask before providing personal care.
• B. Send the UAP to be fitted for a particulate filter mask immediately so she can provide care to this client.
• C. Instruct the UAP that a standard mask is sufficient for the provision of care for the assigned client.
• D. Before changing assignments, determine which staff members have fitted particulate filter masks.

Correct answer: C

Rationale: The correct answer is C. For droplet precautions, such as in the case of pertussis, a standard face mask is sufficient for protection. Particulate filter masks are required for airborne precautions, not for droplet precautions. Therefore, the UAP can proceed with taking the vital signs using a standard mask without the need for a particulate filter mask. Choice A is incorrect because the UAP does not need to get fitted for a particulate filter mask before providing care in this situation. Choice B is incorrect as fitting for a particulate filter mask is not necessary for droplet precautions. Choice D is also incorrect because determining which staff members have fitted particulate filter masks is not relevant to the UAP's situation with the client on droplet precautions. It is important for healthcare workers to understand the appropriate use of personal protective equipment based on the type of precautions in place to provide safe and effective care to clients.

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