Nursing Elites

1. A client who recently had a hip replacement has a strong odor from the urine and bloody drainage on the surgical dressing. What should the nurse do first?

• A. Obtain a urine sample from the bedpan.
• B. Insert an indwelling urinary catheter.
• C. Measure the client's oral temperature.
• D. Remove dressing and assess surgical site.

Correct answer: C

Rationale: The correct answer is to measure the client's oral temperature. In this scenario, the strong odor from urine and bloody drainage on the surgical dressing are concerning signs that suggest a possible infection. Fever is a common sign of infection, so measuring the client's temperature will help confirm if an infection is present. Obtaining a urine sample, inserting an indwelling urinary catheter, or removing the dressing and assessing the surgical site are not the first priority actions when infection is suspected. These actions may be necessary later but assessing the client's temperature is the initial step to evaluate for infection.

2. A client frequently admitted to the locked psychiatric unit repeatedly compliments and invites one of the nurses to go out on a date. The nurse's response should be to

• A. Ask not to be assigned to this client or to work on another unit
• B. Tell the client that such behavior is inappropriate
• C. Inform the client that hospital policy prohibits staff from dating clients
• D. Discuss the boundaries of the therapeutic relationship with the client

Correct answer: D

Rationale: The correct response for the nurse in this situation is to discuss the boundaries of the therapeutic relationship with the client. By doing so, the nurse can reinforce professionalism, establish clear boundaries, and prevent ethical conflicts. Option A is incorrect because avoiding the client or unit does not address the issue at hand and may compromise patient care. Option B, while acknowledging the behavior, does not address the underlying reasons and boundaries. Option C, stating hospital policy, is not as therapeutic or client-centered as discussing the therapeutic relationship directly.

3. A client with a history of asthma reports using an albuterol inhaler more frequently than prescribed. Which action should the nurse take first?

• A. Notify the healthcare provider immediately
• B. Schedule a pulmonary function test
• C. Assess the client's respiratory status
• D. Instruct the client to decrease inhaler use

Correct answer: C

Rationale: Increased use of a rescue inhaler like albuterol may indicate worsening asthma symptoms. The nurse should first assess the client's respiratory status to determine the severity of the issue and the next steps in care. Option A is not the first action because assessing the client's condition should precede notifying the healthcare provider. Option B, scheduling a pulmonary function test, is not the priority as immediate assessment of the client's respiratory status is crucial. Instructing the client to decrease inhaler use should come after assessing the client's condition to ensure the appropriate intervention.

4. A client is experiencing angina at rest. Which statement indicates a good understanding of the care required?

• A. I will notify the nurse if my chest pain is not relieved in 30 minutes.
• B. I will use nitroglycerin as needed, every 5 minutes, up to 3 doses.
• C. I will avoid physical activity until the pain subsides completely.
• D. I will take nitroglycerin 30 minutes before any physical activity.

Correct answer: B

Rationale: The correct answer is B. Using nitroglycerin as needed, every 5 minutes, up to 3 doses, is the appropriate management for angina at rest. This helps dilate blood vessels, improving blood flow to the heart. Choice A is incorrect because chest pain that persists at rest should be addressed immediately, not waiting for 30 minutes. Choice C is incorrect as avoiding physical activity is not a recommended approach during an angina episode. Choice D is incorrect because nitroglycerin should be used during chest pain episodes, not as a preventive measure before physical activity.

5. An older male client, who is a retired chef, is hospitalized with a diabetic ulcer on his foot. His daughter tells the nurse that her father has become increasingly obsessed with the way his food is prepared in the hospital. The nurse's response should be based on what information?

• A. His daughter's observations suggest the client is depressed
• B. His compulsiveness about food may indicate new cognitive decline
• C. Obsessiveness with food is common in diabetic clients
• D. If the client was compulsive about food when he was younger, the aging process can magnify this

Correct answer: D

Rationale: Age can magnify pre-existing compulsive tendencies. If the client was detail-oriented about food earlier in life, this behavior may intensify with aging. It's important to acknowledge and address the client's concerns respectfully. Choices A, B, and C are incorrect because the daughter's observations do not necessarily point to depression, the compulsiveness about food does not indicate new cognitive decline without further assessment, and obsessiveness with food is not specifically common in diabetic clients.

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