Nursing Elites

1. A client's blood pressure reading is 156/94 mm Hg. Which action should the nurse take first?

• A. Inform the client that the blood pressure is high and compare the reading with the client's previously documented blood pressure readings for accuracy.
• B. Contact the health care provider to report the reading and obtain a prescription for an antihypertensive medication.
• C. Replace the cuff with a larger one to ensure a proper fit for the client and increase arm comfort during blood pressure measurement.
• D. Compare the current reading with the client's previously documented blood pressure readings.

Correct answer: D

Rationale: The correct action for the nurse to take first when a client's blood pressure reading is 156/94 mm Hg is to compare the current reading with the client's previously documented readings. This comparison helps determine whether the current reading is abnormal for the client. Option A, which involves informing the client that the blood pressure is high and comparing it with the previous readings, is appropriate as it educates the client and aids in accurate assessment. Option B, contacting the health care provider for medication, is premature without further assessment. Option C, replacing the cuff with a larger one, is incorrect as it may affect the accuracy of the blood pressure measurement and is not a standard practice for managing high blood pressure readings.

2. Urinary catheterization is prescribed for a postoperative female client who has been unable to void for 8 hours. The nurse inserts the catheter, but no urine is seen in the tubing. What should the nurse do next?

• A. Clamp the catheter and recheck it in 60 minutes.
• B. Pull the catheter back 3 inches and redirect upward.
• C. Leave the catheter in place and reattempt with another catheter.
• D. Notify the healthcare provider of a possible obstruction.

Correct answer: C

Rationale: When no urine is seen in the tubing after inserting a catheter in a female client who has not voided for 8 hours, it is possible that the catheter is in the vagina rather than the bladder. Leaving the initial catheter in place can help locate the meatus for the second attempt. The client should have at least 240 mL of urine output after 8 hours, indicating the need for catheterization. Clamping the catheter (Option A) does not address the issue of incorrect catheter placement. Pulling the catheter back and redirecting it (Option B) is not effective unless the catheter is completely removed, requiring a new catheter. There is no indication of a urinary tract obstruction to notify the healthcare provider (Option D) as the catheter could be inserted easily.

3. Which response would the nurse make when a client moans softly, 'Oh no, I'm next. They couldn't protect him, and they can't protect me,' after learning a recently discharged client committed suicide?

• A. ''The other person was a lot sicker than you are.''
• B. 'You seem to be afraid that you'll hurt yourself.''
• C. 'That was different. He was at home, but you're here.''
• D. 'There's no need to worry. You have a better support system.''

Correct answer: B

Rationale: The nurse would make the statement, 'You seem to be afraid that you'll hurt yourself.' This response acknowledges the client's emotional distress and opens up the opportunity for the client to discuss their feelings, showing empathy and understanding. Choice A, 'The other person was a lot sicker than you are,' dismisses the client's emotions and fails to address the underlying fear of self-harm. Choice C, 'That was different. He was at home, but you're here,' invalidates the client's concerns and does not encourage further discussion. Choice D, 'There's no need to worry. You have a better support system,' offers false reassurance and does not address the client's expressed fear, missing an opportunity for therapeutic communication.

4. A nurse is assigned to care for a close friend in the hospital setting. Which action should the nurse take first when given the assignment?

• A. Notify the friend that all medical information will be kept confidential.
• B. Explain the relationship to the charge nurse and ask for reassignment.
• C. Approach the client and ask if the assignment is uncomfortable.
• D. Accept the assignment but protect the client's confidentiality.

Correct answer: B

Rationale: When a nurse is assigned to care for a close friend, it is essential to maintain professional boundaries to ensure the best care for the client and the nurse. The most appropriate action for the nurse to take first is to explain the relationship to the charge nurse and ask for reassignment (B). This is important to avoid potential conflicts of interest and maintain objectivity in the care provided. Option A, notifying the friend about confidentiality, may not address the underlying issue of the conflict of interest. Option C, asking the client if the assignment is uncomfortable, may not be appropriate as it puts the client in a difficult position. Option D, accepting the assignment but protecting the client's confidentiality, does not address the conflict of interest and potential ethical issues that may arise from caring for a close friend.

5. The client with partial-thickness (second-degree) and full-thickness (third-degree) burns is at risk of infection. What intervention has the highest priority in decreasing the client's risk of infection?

• A. Administration of plasma expanders
• B. Use of careful handwashing technique
• C. Application of a topical antibacterial cream
• D. Limiting visitors to the client with burns

Correct answer: B

Rationale: The correct answer is the use of careful handwashing technique. Proper handwashing is the most effective way to prevent the transmission of infectious organisms. Option A, administration of plasma expanders, addresses hypovolemia in burn patients but does not directly decrease the risk of infection. Option C, application of a topical antibacterial cream, is beneficial but not as effective as proper handwashing in preventing infection. Option D, limiting visitors, may help reduce the risk of exposure to pathogens but is not as critical as ensuring healthcare providers maintain strict hand hygiene, which is the cornerstone of infection control in any healthcare setting.

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