Nursing Elites

1. A nurse is caring for a client who is having difficulty voiding following the removal of an indwelling urinary catheter. Which of the following interventions should the nurse take?

• A. Assess for bladder distention after 6 hours
• B. Encourage the client to use a bedpan in the supine position
• C. Restrict the client's intake of oral fluids
• D. Pour warm water over the client's perineum

Correct answer: D

Rationale: The correct answer is to pour warm water over the client's perineum. This intervention can help stimulate voiding after catheter removal by promoting relaxation of the perineal muscles and increasing sensory input to the bladder. Assessing for bladder distention after 6 hours (Choice A) is important but not the initial intervention for difficulty voiding. Encouraging the client to use a bedpan in the supine position (Choice B) may not be effective in promoting voiding. Restricting the client's intake of oral fluids (Choice C) is not appropriate as hydration is important for urinary function.

2. A nurse is performing postmortem care for a client prior to the arrival of the client's family for viewing of the body. Which of the following actions should the nurse take?

• A. Apply moisturizing lotion to the skin
• B. Turn off the lights
• C. Remove all jewelry
• D. Gently close the client's eyelids

Correct answer: D

Rationale: The correct action the nurse should take is to gently close the client's eyelids. This is a respectful and common practice in postmortem care before allowing the family to view the body. Applying moisturizing lotion to the skin is unnecessary and may not be appropriate at this time. Turning off the lights might not be necessary and could impact the viewing environment for the family. While removing all jewelry is generally a good practice, it is not as crucial as gently closing the client's eyelids for postmortem care.

3. What are the primary goals of post-operative care for a patient who has undergone abdominal surgery?

• A. Pain Management
• B. Wound Care
• C. Prevention of Complications
• D. Digestive Function

Correct answer: A

Rationale: The correct answer is A: Pain Management. After abdominal surgery, one of the primary goals of post-operative care is to manage the patient's pain effectively to ensure their comfort and promote recovery. While wound care, prevention of complications, and ensuring digestive function are also important aspects of post-operative care, pain management takes precedence as it directly impacts the patient's well-being and recovery process.

4. A client with a tracheostomy is exhibiting signs of respiratory distress. What should the nurse do first?

• A. Notify the healthcare provider
• B. Suction the tracheostomy
• C. Administer a bronchodilator
• D. Increase the oxygen flow rate

Correct answer: B

Rationale: When a client with a tracheostomy is experiencing respiratory distress, the priority action is to suction the tracheostomy to clear the airway and improve breathing. This helps remove secretions or blockages that may be causing the distress. Notifying the healthcare provider (Choice A) can be done after ensuring immediate airway clearance. Administering a bronchodilator (Choice C) would not address the primary issue of airway clearance in a tracheostomy patient. Increasing the oxygen flow rate (Choice D) may be necessary but should come after ensuring the airway is clear.

5. A nurse is observing an assistive personnel (AP) caring for a client. For which of the following actions by the AP should the nurse intervene?

• A. Providing care in the hallway
• B. Reporting client information in the hallway
• C. Helping another client use the restroom
• D. Feeding the client too quickly

Correct answer: B

Rationale: The correct answer is B because reporting client information in the hallway violates privacy regulations, compromising patient confidentiality. Providing care in the hallway (choice A) may not be ideal but is not a direct violation. Helping another client use the restroom (choice C) shows the AP's willingness to assist but is not a concern unless it compromises the current client's safety. Feeding the client too quickly (choice D) is a potential concern for aspiration but may not require immediate intervention as addressing hydration and swallowing strategies can help prevent complications.

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