Nursing Elites

1. A client has an indwelling urinary catheter. Which of the following interventions should the nurse implement to prevent infection?

• A. Change the catheter every 72 hours.
• B. Ensure the tubing is unkinked.
• C. Empty the drainage bag every 4 hours.
• D. Hang the drainage bag below the bladder.

Correct answer: D

Rationale: The correct answer is to hang the drainage bag below the bladder. This positioning helps prevent backflow of urine, reducing the risk of infection. Changing the catheter every 72 hours is not necessary unless clinically indicated and may increase infection risk by introducing pathogens. Ensuring the tubing is unkinked promotes proper urine flow but does not directly prevent infection. Emptying the drainage bag regularly is important to prevent urinary stasis but does not directly address infection prevention.

2. Which action by the nurse will help reduce the risk of venous thromboembolism (VTE) in a postoperative patient?

• A. Encourage early ambulation and leg exercises.
• B. Apply compression stockings to the patient's legs.
• C. Administer anticoagulants as prescribed.
• D. Elevate the patient's legs to promote circulation.

Correct answer: A

Rationale: The correct answer is to encourage early ambulation and leg exercises. By promoting early ambulation and leg exercises, blood flow is enhanced, reducing the risk of venous thromboembolism (VTE) in postoperative patients. Choice B, applying compression stockings, helps prevent VTE but is not as effective as early ambulation and exercises. Choice C, administering anticoagulants, is important in VTE prevention but does not directly address improving circulation through physical activity. Choice D, elevating the patient's legs, may be beneficial for circulation in specific cases but is not as effective in preventing VTE as early ambulation and leg exercises.

3. A patient requires repositioning every 2 hours. Which task can the nurse delegate to the nursing assistive personnel?

• A. Determining the level of comfort
• B. Changing the patient's position
• C. Identifying immobility hazards
• D. Assessing circulation

Correct answer: B

Rationale: The correct answer is B: 'Changing the patient's position.' Repositioning the patient every 2 hours can be delegated to nursing assistive personnel as it involves physically moving the patient. Tasks like determining the level of comfort (choice A) and assessing circulation (choice D) are clinical judgments that require a nursing license and should be performed by the nurse. Similarly, identifying immobility hazards (choice C) involves critical thinking and assessment skills that are within the nurse's scope of practice.

4. How should a healthcare professional respond to a patient experiencing hypoglycemia?

• A. Rechecking the blood glucose level in 15 minutes
• B. Encouraging the patient to eat a high-protein snack
• C. Administering 15g of fast-acting carbohydrates
• D. Administering glucagon if the patient is unconscious

Correct answer: C

Rationale: The correct response to a patient experiencing hypoglycemia is to administer 15g of fast-acting carbohydrates. This helps quickly increase the blood glucose levels in the patient, addressing the low blood sugar. Rechecking the blood glucose level in 15 minutes (Choice A) may delay necessary intervention, encouraging a high-protein snack (Choice B) is not recommended as it does not rapidly increase blood sugar levels, and administering glucagon if the patient is unconscious (Choice D) is typically done in severe cases of hypoglycemia when the patient is unable to eat or drink.

5. A client is preparing for a surgical procedure but refuses to remove religious jewelry. What is the best course of action?

• A. Proceed with surgery and document the refusal.
• B. Ask the client for permission to secure the jewelry.
• C. Remove the jewelry and store it safely.
• D. Postpone the surgery until the jewelry is removed.

Correct answer: B

Rationale: The best course of action is to ask the client for permission to secure the jewelry. This respects the client's religious beliefs while also ensuring that the jewelry does not interfere during the surgical procedure. Proceeding with surgery without addressing the presence of the jewelry can lead to complications or distress for the client. Removing the jewelry without consent or postponing the surgery solely due to the presence of religious jewelry are not appropriate actions in this situation.

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