Nursing Elites

1. A client with a history of seizures is admitted for monitoring. What should the nurse prioritize?

• A. Ensure the client is on seizure precautions.
• B. Educate the client about seizure triggers.
• C. Monitor for signs of an impending seizure.
• D. Initiate IV access for anti-seizure medication.

Correct answer: A

Rationale: The correct answer is to ensure the client is on seizure precautions. This is crucial in preventing injury during a seizure episode. While educating the client about seizure triggers (choice B) is important for long-term management, it is not the priority when the client is admitted for monitoring. Monitoring for signs of an impending seizure (choice C) is essential but does not address immediate safety concerns. Initiating IV access for anti-seizure medication (choice D) is not the priority unless a seizure occurs and medical intervention is needed.

2. A nurse notices that a colleague has an odor of alcohol while on duty. What is the most appropriate action?

• A. Speak to the colleague in private.
• B. Report the behavior to the nurse manager immediately.
• C. Confront the colleague directly on the floor.
• D. Do nothing and document the situation.

Correct answer: B

Rationale: Reporting the behavior to the nurse manager immediately is the most appropriate action when a nurse suspects a colleague of being impaired while on duty. This is crucial to ensure patient safety and maintain a professional and safe work environment. Speaking to the colleague in private may not address the issue effectively and could potentially put patients at risk if the colleague is indeed impaired. Confronting the colleague directly on the floor may lead to a confrontation and is not the most professional way to handle the situation. Doing nothing and documenting the situation without taking immediate action can jeopardize patient safety and is not an appropriate response when substance use is suspected.

3. A nurse is caring for a patient with heart failure who has developed pulmonary edema. What is the nurse's priority action?

• A. Administer a diuretic as prescribed.
• B. Place the patient in a high Fowler's position.
• C. Administer oxygen via nasal cannula.
• D. Monitor the patient's lung sounds every 2 hours.

Correct answer: B

Rationale: The correct answer is to place the patient in a high Fowler's position. This position helps improve lung expansion and oxygenation in cases of pulmonary edema by reducing venous return to the heart and enhancing respiratory mechanics. Administering a diuretic (Choice A) can be important but is not the priority over positioning in this situation. Administering oxygen (Choice C) is essential, but the priority action for improving oxygenation is the positioning of the patient. Monitoring lung sounds (Choice D) is crucial for ongoing assessment but is not the priority action when the patient is in distress with pulmonary edema.

4. A client with cirrhosis and ascites requires a care plan. Which intervention should the nurse include?

• A. Increase the client's sodium intake
• B. Increase the client's saturated fat intake
• C. Decrease the client's carbohydrate intake
• D. Decrease the client's fluid intake

Correct answer: D

Rationale: In cirrhosis with ascites, decreasing fluid intake is crucial to manage the condition. This helps prevent further fluid accumulation in the abdomen. Increasing sodium intake (Choice A) can worsen fluid retention and edema. Increasing saturated fat intake (Choice B) is not recommended as it can contribute to liver damage. Decreasing carbohydrate intake (Choice C) is not directly related to managing ascites in cirrhosis.

5. A healthcare professional is preparing to insert an indwelling urinary catheter. What is the most important action to prevent infection?

• A. Use sterile gloves during the procedure.
• B. Clean the catheter insertion site with alcohol.
• C. Insert the catheter as quickly as possible.
• D. Use a smaller catheter size to minimize trauma.

Correct answer: A

Rationale: Using sterile gloves during catheter insertion is crucial to prevent infection. Sterile gloves help maintain asepsis during the procedure, reducing the risk of introducing microorganisms into the urinary tract. Cleaning the insertion site with alcohol, as mentioned in choice B, is important but not as critical as using sterile gloves. Choice C, inserting the catheter as quickly as possible, is not recommended as it can lead to errors and increase the risk of contamination. Choice D, using a smaller catheter size to minimize trauma, is not directly related to preventing infection but rather focuses on patient comfort and reducing tissue damage.

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