Nursing Elites

1. A nurse at an assisted living facility is preparing an in-service for residents about electrical safety. Which of the following instructions should the nurse include?

• A. Avoid taping electrical cords to the floor.
• B. Clean electrical equipment before disconnection.
• C. Cover exposed wires with tape before use.
• D. Disconnect electrical equipment by grasping the plug.

Correct answer: A

Rationale: The correct instruction for electrical safety is to avoid taping electrical cords to the floor. Taping cords can create tripping hazards, leading to falls and potential injuries. Choice B, cleaning electrical equipment before disconnection, is not directly related to electrical safety but rather to equipment maintenance. Choice C, covering exposed wires with tape before use, is incorrect as exposed wires should be properly insulated and repaired by a qualified professional. Choice D, disconnecting electrical equipment by grasping the plug, is unsafe and can lead to electrical shocks. It is always recommended to unplug devices by holding the plug itself, not by pulling the cord.

2. A nursing assistive personnel (AP) is providing AM care to patients. Which action by the NAP will require the nurse to intervene?

• A. Not offering a backrub to a patient with fractured ribs
• B. Not offering to wash the hair of a patient with neck trauma
• C. Turning off the television while giving a backrub to the patient
• D. Turning the patient's head with neck injury to the side when giving oral care

Correct answer: D

Rationale: The correct answer is D. Turning a patient's head with a neck injury to the side when giving oral care can lead to harm or further injury. The neck should be kept in a neutral position to prevent exacerbation of the injury. Choices A, B, and C are not actions that require immediate nurse intervention. Not offering a backrub, not washing a patient's hair, or turning off the television are not critical issues that pose harm to the patient's well-being or safety.

3. An 18-year-old client is admitted to the intensive care unit from the emergency room following a diving accident. The injury is suspected to be at the level of the 2nd cervical vertebra. The nurse's priority assessment should be

• A. Response to stimuli
• B. Bladder control
• C. Respiratory function
• D. Muscle strength

Correct answer: C

Rationale: Injuries at the level of the 2nd cervical vertebra can affect the phrenic nerve, leading to potential impairment of respiratory function. Assessing respiratory function is crucial as compromised breathing can quickly escalate to life-threatening situations. While response to stimuli is important, ensuring adequate oxygenation takes precedence due to the immediate threat to life. Bladder control may be affected by spinal cord injuries at higher levels, but it is not the priority in this scenario. Muscle strength is a potential consequence of cervical spinal cord injury, but assessing respiratory function is more critical in the acute phase.

4. The nurse receives a report that a client with an indwelling urinary catheter has an output of 150 mL for the previous 6-hour shift. Which intervention should the nurse implement first?

• A. Check the drainage tubing for a kink
• B. Review the intake and output record
• C. Notify the healthcare provider
• D. Give the client 8 oz of water to drink

Correct answer: A

Rationale: The correct answer is to check the drainage tubing for a kink. A kink in the tubing can obstruct urine flow, potentially causing the low output. By addressing this first, the nurse can ensure that there are no physical obstructions hindering urine drainage. Reviewing the intake and output record is important, but addressing a possible kink in the tubing takes precedence as it directly affects urine flow. Notifying the healthcare provider should be considered after assessing and resolving immediate issues. Giving the client water to drink may be appropriate, but addressing a kink in the tubing is the priority to ensure proper function of the urinary catheter.

5. A client is 6 hours postoperative following abdominal surgery and is having difficulty voiding. Which of the following actions should the nurse take?

• A. Allow the client to hear running water while attempting to void
• B. Provide the client with a bedpan while sitting upright
• C. Insert an indwelling urinary catheter and connect it to gravity drainage
• D. Encourage the client to limit fluid intake

Correct answer: A

Rationale: The correct action for the nurse to take in this situation is to allow the client to hear running water while attempting to void. This can help stimulate the urge to urinate in a non-invasive way, promoting natural voiding. Providing a bedpan while sitting upright is also a suitable approach to facilitate voiding by encouraging a more natural position. Inserting an indwelling urinary catheter should be a last resort due to infection risks and discomfort associated with catheterization. Encouraging the client to limit fluid intake is not appropriate as hydration is crucial for overall health and can aid in promoting voiding. Therefore, the best initial intervention to promote voiding in this scenario is to allow the client to hear running water.

Similar Questions