Nursing Elites

1. A client reports difficulty sleeping while in the hospital. Which of the following actions taken by the assistive personnel (AP) while the client is sleeping should prompt the nurse to intervene?

• A. Closes the door to the client's room
• B. Flushes the client's toilet after emptying the urinary catheter's drainage bag
• C. Measures the client's vital signs routinely
• D. Asks a group of personnel in the hall to speak quietly

Correct answer: B

Rationale: The correct answer is B because flushing the client's toilet after emptying the urinary catheter's drainage bag could disturb the client's rest. The nurse should intervene to ensure a restful environment for the client. Choices A, C, and D are not actions that would be disruptive to the client's sleep. Closing the door to the client's room, measuring vital signs routinely, and asking personnel in the hall to speak quietly are appropriate actions that do not directly disturb the client's rest.

2. How should a nurse respond to a client with terminal cancer who has requested a change in the level of pain medication?

• A. Increase the dosage without consulting the healthcare provider.
• B. Consult with the healthcare provider to adjust the medication.
• C. Ignore the request as the client is near the end of life.
• D. Increase the medication to reduce pain faster.

Correct answer: B

Rationale: The correct answer is to consult with the healthcare provider to adjust the medication. It is crucial for the healthcare provider to be involved in changing pain medication for a client with terminal cancer to ensure that the new dosage is appropriate and safe. Option A is incorrect because adjusting medication without consulting the healthcare provider can be dangerous and is not within the scope of the nurse's practice. Option C is incorrect because ignoring the client's request goes against the principles of patient-centered care. Option D is incorrect as the primary goal should be to provide effective pain relief with the appropriate dosage, not to increase the medication arbitrarily.

3. A patient prescribed warfarin is being taught about dietary restrictions by a healthcare provider. Which of the following foods should the patient be instructed to limit?

• A. Bananas
• B. Spinach
• C. Potatoes
• D. Apples

Correct answer: B

Rationale: The correct answer is B: Spinach. Spinach is high in vitamin K, which can interfere with the effectiveness of warfarin, an anticoagulant medication. Patients taking warfarin should limit foods high in vitamin K to maintain the medication's effectiveness and consistent dosage. Bananas, potatoes, and apples are not high in vitamin K and do not typically interfere with warfarin therapy.

4. A client asks about becoming an organ donor. What information should the nurse provide?

• A. The process should be discussed with family first.
• B. The organ donation process should begin immediately.
• C. Organ donation can proceed even if the family disagrees.
• D. Donor cards must be signed in the presence of a witness.

Correct answer: D

Rationale: The correct answer is D. For organ donation to be legally valid, the donor must sign consent documents in the presence of a witness. Choice A is incorrect because while discussing with family is important, it is not a legal requirement for organ donation. Choice B is incorrect as the organ donation process involves various steps and procedures that cannot begin immediately. Choice C is incorrect because organ donation typically requires consent and cooperation from the family if the donor is unable to provide consent.

5. Which principle is most important for maintaining medical asepsis in a healthcare setting?

• A. Sterilize instruments only when visibly contaminated.
• B. Use sterile gloves for all patient interactions.
• C. Disinfect patient areas only at the end of the day.
• D. Clean hands thoroughly before and after patient contact.

Correct answer: D

Rationale: The correct answer is D: Clean hands thoroughly before and after patient contact. Hand hygiene is crucial for maintaining medical asepsis in a healthcare setting as it helps prevent the spread of infections between patients and healthcare workers. Choice A is incorrect because instruments should be sterilized regularly, not just when visibly contaminated. Choice B is incorrect as sterile gloves are not required for all patient interactions, only for specific procedures. Choice C is incorrect because patient areas should be disinfected regularly throughout the day, not just at the end of the day.

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