A client's daughter phones the charge nurse to report that the night nurse did not provide good care for her mother. What response should the nurse make?

A. Explain that all staff are doing their best

B. Ask for a description of what happened during the night

C. Tell the daughter to talk to the unit's nurse manager

D. Reassure the daughter that the mother will get better care

Correct Answer: B
Rationale: The correct response for the nurse in this situation is to ask for a description of what happened during the night. This allows the nurse to gather specific information about the care provided and address the complaint appropriately. Choice A is incorrect because dismissing the concern by stating that all staff are doing their best does not address the specific complaint. Choice C is not the best immediate response as the charge nurse should first gather information before escalating the issue to the nurse manager. Choice D is incorrect as it focuses on reassurance without addressing the reported issue.

A client with type 1 diabetes is experiencing symptoms of hypoglycemia. What is the nurse's priority intervention?

• A. Administer glucagon intramuscularly
• B. Provide a complex carbohydrate snack
• C. Administer 50% dextrose intravenously
• D. Give 15 grams of a fast-acting carbohydrate

Correct Answer: D
Rationale: The priority intervention for a client with type 1 diabetes experiencing symptoms of hypoglycemia is to give 15 grams of a fast-acting carbohydrate. In a hypoglycemic state, the priority is to quickly raise the blood glucose level. Administering glucagon intramuscularly (Choice A) is reserved for severe hypoglycemia when the client is unable to take oral carbohydrates. Providing a complex carbohydrate snack (Choice B) is beneficial after the initial treatment of hypoglycemia to prevent recurrence. Administering 50% dextrose intravenously (Choice C) is a more invasive intervention typically done in a hospital setting for severe cases.

During a manic episode, what is the most appropriate intervention to implement first for a client with bipolar disorder?

• A. Engage the client in a quiet activity
• B. Provide a structured environment with minimal stimulation
• C. Monitor the client continuously
• D. Adjust the lighting and noise levels

Correct Answer: B
Rationale: During a manic episode, individuals with bipolar disorder may experience sensory overload and agitation. Providing a structured environment with minimal stimulation is the most appropriate initial intervention as it can help reduce overwhelming sensory input and promote a sense of calm. Engaging the client in a quiet activity (Choice A) may not be effective if the environment is still overstimulating. Continuous monitoring (Choice C) is important but may not be the first intervention needed. Adjusting lighting and noise levels (Choice D) can be helpful but may not address the core issue of sensory overload and agitation during a manic episode.

The nurse is caring for a client with an indwelling urinary catheter. What is the most important action to prevent catheter-associated urinary tract infections (CAUTI)?

• A. Perform hand hygiene before and after handling the catheter
• B. Change the catheter every 72 hours
• C. Apply antibiotic ointment at the insertion site
• D. Irrigate the catheter daily

Correct Answer: A
Rationale: Performing hand hygiene before and after handling the catheter is crucial in preventing catheter-associated urinary tract infections (CAUTI). This practice helps minimize the risk of introducing harmful microorganisms into the urinary tract. Changing the catheter every 72 hours is not recommended unless clinically indicated as it can increase the risk of infection. Applying antibiotic ointment at the insertion site is not a standard practice and may contribute to antibiotic resistance. Irrigating the catheter daily is unnecessary and can introduce pathogens into the urinary tract, increasing the risk of infection.

The nurse is planning to ambulate a client who has been on bed rest for 24 hours following a Colon Resection. To ambulate this client safely, which intervention should the nurse implement first?

• A. Place non-skid shoes on the client
• B. Show the client how to use the call light
• C. Use a gait belt to support the client
• D. Assist the client to a bedside sitting position

Correct Answer: D
Rationale: To ambulate a client safely after a period of bed rest, the nurse should first assist the client to a bedside sitting position. This initial step ensures the client is stable before attempting to stand and walk, reducing the risk of falls and allowing for a gradual adjustment to activity post-bed rest. Placing non-skid shoes, showing how to use the call light, or using a gait belt are important but should come after ensuring the client is safely seated and stable.