Nursing Elites

1. A client is experiencing difficulty voiding following the removal of an indwelling catheter. What action should the nurse take to assist the client?

• A. Assess for bladder distention after 4 hours
• B. Pour warm water over the perineum
• C. Restrict the client's oral fluid intake
• D. Restrict movement for at least 12 hours

Correct answer: B

Rationale: The correct action for the nurse to assist the client who is experiencing difficulty voiding after the removal of an indwelling catheter is to pour warm water over the perineum. This technique can help stimulate urination by promoting relaxation of the perineal muscles and improving blood flow to the area. Assessing for bladder distention after 4 hours (Choice A) is important but not the immediate intervention needed to assist the client in voiding. Restricting the client's oral fluid intake (Choice C) can exacerbate the issue by reducing urine production. Restricting movement for at least 12 hours (Choice D) is unnecessary and may lead to discomfort and other complications.

2. What is the best approach to assist a client in performing self-care after an acute myocardial infarction, when the client expresses concern about fatigue?

• A. Provide clear instructions on how to ask for assistance
• B. Gradually resume self-care tasks, focusing on rest periods
• C. Encourage assistive personnel to complete self-care tasks
• D. Encourage the client to remain in bed until fully rested

Correct answer: B

Rationale: The best approach to assist a client in performing self-care after an acute myocardial infarction, especially when the client expresses concern about fatigue, is to gradually resume self-care tasks while focusing on rest periods. This approach allows the client to build confidence in managing their self-care activities while also addressing the issue of fatigue. Choice A is incorrect as it focuses on asking for assistance rather than promoting self-care. Choice C is inappropriate as it suggests delegating the client's self-care tasks to assistive personnel instead of empowering the client. Choice D is incorrect as it can lead to deconditioning and is not conducive to the client's recovery process.

3. A nurse in the emergency department is caring for a client who has full-thickness burns of the thorax and upper torso. After securing the client's airway, which of the following is the nurse's priority intervention?

• A. Providing pain management.
• B. Offering emotional support.
• C. Preventing infection.
• D. Initiating IV fluids.

Correct answer: D

Rationale: After securing the airway, initiating IV fluids is the priority to prevent hypovolemic shock in clients with severe burns. IV fluids help maintain circulating volume and prevent a drop in blood pressure due to fluid loss. Providing pain management, offering emotional support, and preventing infection are important aspects of care but are secondary to ensuring adequate fluid resuscitation in clients with severe burns.

4. When a nurse questions a medication prescription as too extreme due to a client's advanced age and unstable status, this action exemplifies which ethical principle?

• A. Fidelity
• B. Autonomy
• C. Justice
• D. Non-maleficence

Correct answer: D

Rationale: The correct answer is D: Non-maleficence. Non-maleficence refers to the ethical principle of avoiding harm. In this scenario, the nurse questions the medication prescription to prevent potential harm to the client, demonstrating the principle of non-maleficence. Choice A, fidelity, pertains to being faithful and keeping promises, which is not the focus of the scenario. Choice B, autonomy, relates to respecting a client's right to make decisions about their care, not the nurse's actions. Choice C, justice, involves fairness and equal treatment, which is not directly applicable to the nurse questioning a medication prescription to prevent harm.

5. A healthcare professional is collecting data from a client who is experiencing post-traumatic stress disorder (PTSD). Which of the following manifestations should the healthcare professional expect?

• A. Hyperactivity
• B. Hypervigilance
• C. Restlessness
• D. Avoidance of social situations

Correct answer: B

Rationale: Hypervigilance is a common manifestation of PTSD characterized by heightened alertness and fear of danger. This heightened state of awareness can lead to irritability, difficulty concentrating, and sleep disturbances. Choices A, C, and D are incorrect. Hyperactivity is not typically associated with PTSD; restlessness may be present but is not the primary manifestation, and avoidance of social situations is more commonly seen in conditions like social anxiety disorder rather than PTSD.

Similar Questions