Nursing Elites

1. A client with frequent urinary tract infections (UTIs) asks the nurse about drinking juice daily to prevent future UTIs. Which response is best for the nurse to provide?

• A. Orange juice has vitamin C, which deters bacterial growth.
• B. Apple juice is the most useful in acidifying the urine.
• C. Cranberry juice stops pathogens' adherence to the bladder.
• D. Grapefruit juice increases the absorption of most antibiotics.

Correct answer: C

Rationale: Cranberry juice is known for its ability to prevent urinary tract infections by reducing the adherence of Escherichia coli bacteria to the cells within the bladder. This property helps in maintaining urinary tract health and preventing recurrent UTIs. Choices A, B, and D are incorrect because while vitamin C in orange juice may have some benefits, it is not specifically known for deterring bacterial growth in the urinary tract. Apple juice does not significantly impact urine acidity, and grapefruit juice does not enhance antibiotic absorption, making them less effective choices for preventing UTIs compared to cranberry juice.

2. While suctioning a tracheostomy tube, the client starts to cough. What is the best action for the nurse to take?

• A. Suction deeper to remove secretions.
• B. Gently withdraw suction tubing to allow suction or coughing out of mucus.
• C. Remove the suction as quickly as possible.
• D. Insert and remove the suction multiple times to clear secretions.

Correct answer: B

Rationale: When a client coughs during tracheostomy tube suctioning, the nurse should gently withdraw the suction tubing. This action allows the client to cough out mucus naturally, reducing the risk of further irritation and promoting effective airway clearance. Choice A is incorrect because suctioning deeper can cause trauma and increase the risk of complications. Choice C is incorrect as removing the suction quickly may not allow the client to clear the mucus adequately. Choice D is incorrect as inserting and removing the suction multiple times can lead to unnecessary trauma and discomfort for the client.

3. When a male client mentions his foot is hurting while watching TV with his wife, how should the nurse respond?

• A. Ask him to rate his pain on a scale of 1 to 10.
• B. Encourage him to wait until bedtime for the pill to help him sleep.
• C. Attend to an acutely ill client's needs first as the client is laughing.
• D. Instruct him in the use of deep breathing exercises for pain control.

Correct answer: A

Rationale: The correct response is to ask the client to rate his pain on a scale of 1 to 10. This helps the nurse assess the intensity of the pain and determine the appropriate pain medication. Encouraging him to wait or attend to another client's needs first are incorrect because pain management should be addressed promptly. Instructing on deep breathing exercises may be helpful but is not the initial step in addressing acute pain.

4. The healthcare provider is assessing the nutritional status of several clients. Which client has the greatest nutritional need for additional intake of protein?

• A. A college-age track runner with a sprained ankle.
• B. A lactating woman nursing her 3-day-old infant.
• C. A school-aged child with Type 2 diabetes.
• D. An elderly man being treated for a peptic ulcer.

Correct answer: B

Rationale: A lactating woman (B) has the greatest need for additional protein intake. Lactation increases the metabolic demands for protein to support milk production, making it essential for the mother to have a higher protein intake. While clients in choices A, C, and D also require protein for various reasons, they do not have the same increased protein demands as a lactating woman. Choice A, a college-age track runner with a sprained ankle, may need protein for tissue repair but not at the level required during lactation. Choice C, a school-aged child with Type 2 diabetes, may benefit from protein for overall health but does not have the same increased protein needs as a lactating woman. Choice D, an elderly man being treated for a peptic ulcer, may need protein for healing but not to the extent required by a lactating woman.

5. When assisting an older client who can stand but not ambulate from the bed to a chair, what is the best action for the nurse to implement?

• A. Use a mechanical lift to transfer the client from the bed to a chair.
• B. Place a roller board under the client who is sitting on the side of the bed and slide the client to the chair.
• C. Lift the client out of bed to the chair with another staff member using a coordinated effort on the count of three.
• D. Place a transfer belt around the client, assist the client to stand, and pivot to a chair that is placed at a right angle to the bed.

Correct answer: D

Rationale: The best action for the nurse when assisting an older client who can stand but not ambulate from the bed to a chair is to use a transfer belt. Placing a transfer belt around the client, assisting the client to stand, and pivoting to a chair that is placed at a right angle to the bed allows for a safe and controlled transfer. This method promotes patient independence while ensuring safety during the transfer process. Choices A, B, and C are incorrect because using a mechanical lift may not be necessary for a client who can stand, using a roller board may not provide enough stability, and lifting the client with the help of another staff member may not be the safest option for the client's independence and safety.

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