Nursing Elites

1. A nurse in a long-term care facility is admitting a client who is incontinent and smells strongly of urine. His partner, who has been caring for him at home, is embarrassed and apologizes for the smell. Which of the following responses should the nurse make?

• A. "It must be difficult to care for someone who is confined to bed."
• B. "It is important to keep the client clean to avoid infections."
• C. "I understand that this is challenging; let’s work together to ensure comfort."
• D. "The smell is quite strong; we need to address this immediately."

Correct answer: C

Rationale: The correct response is C: "I understand that this is challenging; let’s work together to ensure comfort." This response acknowledges the difficulty the partner is facing, shows empathy, and offers to collaborate in providing care. Choice A is incorrect because it does not directly address the partner's feelings of embarrassment or offer support. Choice B, while true, does not address the partner's emotional state and may come across as directive rather than supportive. Choice D is also incorrect as it focuses solely on the smell without addressing the partner's emotions or offering assistance in managing the situation with empathy.

2. Nurse talking with a client’s partner. She is having frustrations about managing responsibilities and care. What type of role performance stress is this?

• A. Role overload
• B. Role conflict
• C. Role ambiguity
• D. Role strain

Correct answer: A

Rationale: Role overload occurs when a person feels overwhelmed by the demands placed upon them.

3. The healthcare professional prepares a 1,000 ml IV of 5% dextrose and water to be infused over 8 hours. The infusion set delivers 10 drops per milliliter. The healthcare professional should regulate the IV to administer approximately how many drops per minute?

• A. 80
• B. 8
• C. 21
• D. 25

Correct answer: C

Rationale: To calculate the drops per minute for the IV infusion, first determine the total drops to be infused over 8 hours. 1,000 ml to be infused over 8 hours means 125 ml per hour (1000 ml / 8 hours = 125 ml/hr). Since the infusion set delivers 10 drops per ml, 125 ml/hr x 10 drops/ml = 1250 drops/hr. To find drops per minute, divide the drops per hour by 60 (minutes in an hour): 1250 drops/hr / 60 minutes = 20.83 drops/minute, which rounds up to 21 drops per minute (Option C). This rate ensures the correct infusion rate over 8 hours. Choices A, B, and D are incorrect calculations and do not provide the appropriate infusion rate needed to administer the IV over the specified time period.

4. An assistive personnel (AP) is assisting a nurse with the care of a female client who has an indwelling urinary catheter. Which of the following actions by the AP indicates a need for further teaching?

• A. The AP hangs the collection bag below the level of the bladder.
• B. The AP performs hand hygiene before handling the catheter.
• C. The AP secures the catheter to the client’s leg with tape.
• D. The AP empties the collection bag when it is full.

Correct answer: A

Rationale: Hanging the collection bag below the level of the bladder is the correct technique for maintaining proper drainage and preventing backflow in a client with an indwelling urinary catheter. Therefore, choice A is the correct answer as it indicates a need for further teaching. Choices B, C, and D demonstrate appropriate actions in catheter care. Performing hand hygiene before handling the catheter helps prevent infection, securing the catheter to the client’s leg with tape prevents accidental dislodgement, and emptying the collection bag when it is full ensures that the catheter functions effectively.

5. A client is scheduled for an IVP (Intravenous Pyelogram). Which of the following data from the client's history indicates a potential hazard for this test?

• A. Reflex incontinence
• B. Allergic to shellfish
• C. Claustrophobia
• D. Hypertension

Correct answer: B

Rationale: The correct answer is B, 'Allergic to shellfish.' An allergy to shellfish can indicate a sensitivity to iodine, which is used in the contrast dye for an IVP, posing a risk of an allergic reaction. Reflex incontinence (Choice A) is not directly related to the potential hazard of an IVP. Claustrophobia (Choice C) and hypertension (Choice D) are also not significant factors that indicate a potential hazard for an IVP.

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