Nursing Elites

1. A nurse is caring for a client who is 2 hours postoperative following a colon resection. Which of the following assessments is the nurse's priority?

• A. Capillary refill
• B. Bowel sounds
• C. Temperature
• D. Oxygen saturation

Correct answer: D

Rationale: The correct answer is D: Oxygen saturation. The priority assessment in this situation is oxygen saturation because postoperative clients are at risk for respiratory complications, such as hypoxia due to factors like anesthesia effects, impaired lung function, or pain interfering with deep breathing. Monitoring oxygen saturation is crucial to detect any respiratory compromise early. Capillary refill, bowel sounds, and temperature are important assessments but are not the priority in this immediate postoperative period.

2. During the admission of a client with a latex allergy, which of the following supplies has the potential to contain latex?

• A. Urinary catheters
• B. Indwelling catheters
• C. Sterile gloves
• D. Sterile gowns

Correct answer: A

Rationale: The correct answer is A: Urinary catheters. Urinary catheters often contain latex, which can trigger an allergic reaction in clients with latex allergy. Indwelling catheters (choice B), sterile gloves (choice C), and sterile gowns (choice D) can be latex-free alternatives. However, urinary catheters are more commonly made with latex, making them a higher risk for clients with latex allergies.

3. A nurse is providing care for a client with dementia who frequently wanders. What is the best strategy to ensure their safety?

• A. Use restraints to prevent wandering
• B. Encourage the client to walk in a monitored area
• C. Place a bed exit alarm system
• D. Ask family members to stay with the client at all times

Correct answer: C

Rationale: The best strategy to ensure the safety of a client with dementia who frequently wanders is to place a bed exit alarm system. This system alerts staff when the client attempts to leave the bed, reducing the risk of falls. Choice A, using restraints, is not the best approach as it can lead to complications and is not recommended unless absolutely necessary. Choice B, encouraging the client to walk in a monitored area, may not be effective in preventing wandering as the client may still wander away. Choice D, asking family members to stay with the client at all times, may not be feasible or practical, especially for round-the-clock supervision.

4. A charge nurse is teaching new staff members about factors that increase a client's risk of becoming violent. Which of the following risk factors should the nurse include as the best predictor of future violence?

• A. Experiencing delusions.
• B. Male gender.
• C. Previous violent behavior.
• D. A history of being in prison.

Correct answer: C

Rationale: The correct answer is C: Previous violent behavior. This is considered the best predictor of future violent actions as individuals who have a history of violent behavior are more likely to engage in violent acts again. Option A, experiencing delusions, although it can impact behavior, is not as strong of a predictor as past violent behavior. Option B, male gender, is a demographic factor but not as specific or predictive as a history of violence. Option D, a history of being in prison, may indicate past behavior but is not directly linked to future violent actions as a known history of violence.

5. What is the appropriate intervention for fluid overload?

• A. Restrict fluid intake
• B. Administer diuretics
• C. Monitor vital signs
• D. All of the above

Correct answer: D

Rationale: The appropriate intervention for fluid overload involves a combination of measures, including restricting fluid intake to prevent further fluid accumulation, administering diuretics to help the body eliminate excess fluids, and closely monitoring vital signs to assess the patient's response to treatment. Therefore, all of the above options are correct. Restricting fluid intake alone may not be sufficient to address existing fluid overload without additional measures like diuretic therapy. Monitoring vital signs is essential to evaluate the effectiveness of the interventions and the patient's overall condition.

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