Nursing Elites

1. A client with a severe prostatic infection that caused a blocked urethra is 3 days post-surgical urinary diversion. The healthcare provider directs the nurse to remove the suprapubic catheter to allow the client to void normally. Which intervention should the nurse implement first?

• A. Cleanse the site around the catheter
• B. Use a 20 ml syringe to deflate balloon
• C. Clamp catheter until the client voids naturally
• D. Empty urine from the urinary drainage bag

Correct answer: B

Rationale: The correct answer is to use a 20 ml syringe to deflate the balloon first when removing a suprapubic catheter. This step is essential to ensure the safe removal of the catheter without causing any harm or discomfort to the client. Deflating the balloon allows for the catheter to be easily removed. Option A, cleansing the site around the catheter, is not the initial step in this process and can be done after catheter removal. Option C, clamping the catheter until the client voids naturally, is incorrect as it can lead to complications like urinary retention. Option D, emptying urine from the urinary drainage bag, is not the first step in removing the suprapubic catheter and does not address the need to deflate the balloon for safe removal.

2. After learning that she has terminal pancreatic cancer, a female client becomes very angry and says to the nurse, 'God has abandoned me. What did I do to deserve this?' Based on this response, the nurse decides to include which nursing problem in the client’s plan of care?

• A. Ineffective coping
• B. Spiritual distress
• C. Acute pain
• D. Complicated grieving

Correct answer: B

Rationale: The client’s expression of feeling abandoned by God indicates spiritual distress, which is a significant issue that needs to be addressed in the plan of care. The individual is questioning their faith and seeking answers in a higher power, which aligns with spiritual distress. Choices A, C, and D are not as directly related to the client's current emotional and spiritual struggle. Ineffective coping may be a consequence of spiritual distress, acute pain is not the primary concern in this scenario, and complicated grieving is premature as the client is still processing the diagnosis and seeking meaning.

3. For a client with pneumonia, the prescription states, “Oxygen at liters/min per nasal cannula PRN difficult breathing.” Which nursing intervention is effective in preventing oxygen toxicity?

• A. Avoiding the administration of oxygen at high levels for extended periods.
• B. Administering a sedative at bedtime to slow the client’s respiratory rate.
• C. Removing the nasal cannula during the night to prevent oxygen buildup.
• D. Running oxygen through a hydration source prior to administration.

Correct answer: A

Rationale: Choice A is the correct answer because prolonged exposure to high levels of oxygen can lead to oxygen toxicity. Administering oxygen at high levels for extended periods can overwhelm the body's natural defenses against high oxygen levels, causing toxicity. Choices B, C, and D are incorrect. Choice B is unrelated to preventing oxygen toxicity. Choice C is unsafe as removing the nasal cannula can deprive the client of necessary oxygen. Choice D, running oxygen through a hydration source, is not a standard practice for preventing oxygen toxicity.

4. A client taking clopidogrel reports the onset of diarrhea. Which nursing action should the nurse implement first?

• A. Observe the appearance of the stool
• B. Assess the client’s skin turgor
• C. Review the client’s laboratory values
• D. Auscultate the client’s bowel sounds

Correct answer: A

Rationale: Observing the stool’s appearance should be implemented first as it helps determine the nature and possible severity of the diarrhea, which is essential in managing the side effect. Assessing skin turgor (Choice B) is not the priority in this situation. Reviewing laboratory values (Choice C) can provide additional information but is not the initial step. Auscultating bowel sounds (Choice D) is not the priority when the client is experiencing diarrhea.

5. A male client approaches the nurse with an angry expression on his face and raises his voice, saying, “My roommate is the most selfish, self-centered, angry person I have ever met. If he loses his temper one more time with me, I am going to punch him out.” The nurse recognizes that the client is using which defense mechanism?

• A. Denial
• B. Splitting
• C. Projection
• D. Rationalization

Correct answer: C

Rationale: The client is projecting his feelings of anger and frustration onto his roommate, attributing his own feelings to the other person. Projection is a defense mechanism where individuals attribute their thoughts, feelings, or motives onto another person. In this scenario, the client is displacing his anger onto his roommate, thereby using projection as a defense mechanism. Denial (choice A) is refusing to acknowledge an aspect of reality. Splitting (choice B) involves viewing people as all good or all bad. Rationalization (choice D) is creating logical explanations to justify unacceptable behavior.

Similar Questions