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. Ten minutes after signing an operative permit for a fractured hip, an older client states, 'The aliens will be coming to get me soon!' and falls asleep. Which action should the nurse implement next?

• A. Make the client comfortable and allow the client to sleep.
• B. Assess the client's neurologic status.
• C. Notify the surgeon about the comment.
• D. Ask the client's family to co-sign the operative permit.

Correct answer: B

Rationale: The nurse should assess the client's neurologic status next. The client's statement about aliens and subsequent falling asleep could be indicative of a potential neurological issue such as confusion or altered mental status. It is essential to assess the client's neurological status to determine the underlying cause of the client's statement and behavior. This assessment will help the nurse identify any potential cognitive impairment or neurological deficits that may need immediate attention, ensuring the client's safety and well-being. Notifying the surgeon or involving the client's family can be considered later, but the priority is to assess the client's neurologic status to address any immediate concerns.

3. The nurse plans to assist a male client out of bed for the first time since his surgery yesterday. His wife objects and tells the nurse to get out of the room because her husband is too ill to get out of bed. What should the nurse do first?

• A. Administer nasal oxygen at a rate of 5 L/min
• B. Help the client to lie back down in the bed
• C. Quickly pivot the client to the chair and elevate the legs
• D. Check the client’s blood pressure and pulse

Correct answer: D

Rationale: Before assisting the client out of bed, the nurse should first assess the client's blood pressure and pulse. This assessment is crucial to determine the client's physiological stability and readiness for ambulation. It ensures the client's safety during the transfer and helps prevent any potential complications that may arise from getting out of bed. Administering oxygen, lying the client back down, or quickly moving the client to a chair without assessing vital signs can compromise the client's safety and may lead to adverse outcomes.

4. An older client who had abdominal surgery 3 days earlier was given a barbiturate for sleep and is now requesting to go to the bathroom. Which action should the nurse implement?

• A. Assist the client to walk to the bathroom and do not leave the client alone.
• B. Request that the UAP assist the client onto a bedpan.
• C. Ask if the client needs to have a bowel movement or void.
• D. Assess the client's bladder to determine if the client needs to urinate.

Correct answer: A

Rationale: Barbiturates cause central nervous system (CNS) depression, increasing the risk of falls. It is crucial for the nurse to assist the client to the bathroom to prevent potential injuries. Leaving the client alone may lead to accidents due to the effects of the medication. Monitoring and supporting the client during this activity is essential for ensuring safety and preventing falls.

5. When entering the room of an adult male, the nurse finds that the client is very anxious. Before providing care, what action should the nurse take first?

• A. Divert the client’s attention
• B. Call for additional help from staff
• C. Document the planned action
• D. Re-assess the client's situation

Correct answer: D

Rationale: Before providing care to an anxious client, it is crucial for the nurse to first re-assess the client's situation. By re-assessing, the nurse can understand the underlying cause of the client's anxiety, which will help in tailoring appropriate care interventions. Re-assessment ensures that care provided is individualized and addresses the client's specific needs, promoting effective and client-centered care delivery. Diverting the client’s attention (Choice A) may not address the root cause of the anxiety. Calling for additional help (Choice B) may be necessary in some situations but should not be the first action. Documenting the planned action (Choice C) should come after re-assessing the client's situation to ensure accurate documentation based on the current assessment.

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