Nursing Elites

1. A client is admitted for observation and has full range of motion. Which is the best manner to encourage the client to void?

• A. Urinal
• B. Bedpan
• C. Bedside Commode
• D. Client Bathroom

Correct answer: D

Rationale: The correct answer is D: Client Bathroom. Encouraging the client to use the bathroom is the best way to promote independence and privacy, maintaining normal function. In this case, since the client has full range of motion, using the client bathroom would be the most appropriate choice. Options A, B, and C (Urinal, Bedpan, Bedside Commode) are not the best choices as they may restrict the client's independence and privacy, which can impact their psychological well-being and normal voiding function.

2. A nurse receives a report from an assistive personnel that a client's BP is 160/95. What should the nurse do first?

• A. Notify the healthcare provider
• B. Recheck the client's BP
• C. Document the findings
• D. Administer antihypertensive medication

Correct answer: B

Rationale: The correct answer is to recheck the client's BP. It is essential for the nurse to verify the accuracy of the initial reading by reassessing the blood pressure. Notifying the healthcare provider or administering antihypertensive medication should only occur after confirming the elevated blood pressure through a recheck. Documenting the findings is important but should follow the confirmation of the BP reading.

3. A nurse is preparing to perform a sterile dressing change for a client with a surgical wound. Which action should the nurse take to prevent contamination during the dressing change?

• A. Proceed with the dressing change
• B. Restart the procedure if the sterile solution splashes onto the sterile field
• C. Continue without concern for minor splashes
• D. Delegate the task to another nurse

Correct answer: B

Rationale: The correct action for the nurse to take to prevent contamination during a sterile dressing change is to restart the procedure if the sterile solution splashes onto the sterile field. Any contamination of the sterile field compromises the aseptic technique and increases the risk of infection for the client. Therefore, it is crucial to maintain the sterility of the field throughout the procedure. Choices A, C, and D are incorrect because proceeding with the dressing change, continuing without concern for minor splashes, or delegating the task to another nurse would all compromise the sterility of the procedure and increase the risk of infection for the client.

4. A nurse is providing dietary teaching to a client who is at risk for cardiovascular disease. Which of the following foods should the nurse recommend?

• A. Fried chicken
• B. Oatmeal
• C. Bacon
• D. Whole milk

Correct answer: B

Rationale: Oatmeal is high in fiber, which helps lower cholesterol levels, making it a heart-healthy food option for clients at risk for cardiovascular disease. Fried chicken, bacon, and whole milk are high in saturated fats and cholesterol, which can increase the risk of heart disease and should be limited in the diet of individuals at risk for cardiovascular issues.

5. A nurse is assessing a client 2 hours after a vaginal delivery and notes that the client's uterus is boggy and displaced to the right. Which of the following interventions should the nurse perform first?

• A. Assist the client to void
• B. Massage the uterus
• C. Administer oxytocin
• D. Encourage breastfeeding

Correct answer: A

Rationale: A boggy and displaced uterus is often a sign of bladder distention, which can prevent the uterus from contracting effectively. The priority intervention is to assist the client to void. By emptying the bladder, the uterus can return to midline and become firm. Massaging the uterus or administering oxytocin may be necessary but should come after addressing the bladder distention. Encouraging breastfeeding is important for uterine contraction but is not the priority in this situation.

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