Nursing Elites

1. A client reports difficulty sleeping at night, which interferes with daily functioning. Which intervention should the nurse suggest to this client?

• A. Avoid beverages containing caffeine
• B. Take a sleep medication regularly at bedtime
• C. Watch television for 30 minutes in bed to relax before falling asleep
• D. Advise the client to take several naps during the day

Correct answer: A

Rationale: The correct answer is A: Avoid beverages containing caffeine. Caffeine is a stimulant that can interfere with sleep, making it difficult for the client to fall asleep at night. Taking sleep medication regularly (choice B) may not address the root cause of the sleep difficulty and can lead to dependency. Watching television in bed (choice C) can actually stimulate the brain and hinder relaxation before sleep. Advising the client to take several naps during the day (choice D) can disrupt the sleep-wake cycle further. Therefore, recommending the avoidance of caffeine-containing beverages is the most appropriate intervention to help the client improve their ability to sleep at night and function better during the day.

2. A client is receiving continuous enteral feedings. Which of the following interventions should the nurse implement?

• A. Monitor intake and output every 8 hours.
• B. Flush the feeding tube every 4 hours.
• C. Measure the client's temperature every 24 hours.
• D. Change the feeding bag and tubing every 72 hours.

Correct answer: B

Rationale: The correct answer is B: Flush the feeding tube every 4 hours. Flushing the feeding tube every 4 hours is essential to maintain patency and prevent clogging, ensuring the client receives the prescribed enteral nutrition without interruption. This intervention helps prevent complications such as tube occlusion. Monitoring intake and output is important for assessing the client's hydration status but does not directly address tube patency. Measuring the client's temperature is essential for monitoring for signs of infection but is not directly related to tube maintenance. Changing the feeding bag and tubing every 72 hours is important for infection control but does not address tube patency.

3. A healthcare professional is planning to collect a stool specimen for ova and parasites from a client with diarrhea. Which of the following actions should the healthcare professional take when collecting the specimen?

• A. Instruct the client to defecate into a clean container
• B. Transfer the specimen to a sterile container
• C. Refrigerate the collected specimen
• D. Place the stool specimen collection container in a biohazard bag

Correct answer: D

Rationale: When collecting a stool specimen for ova and parasites, it is essential to place the specimen collection container in a biohazard bag. This practice ensures proper handling of potentially infectious material and prevents contamination with microorganisms. The biohazard bag should be labeled with the client's information for easy identification and proper tracking throughout the testing process. Instructing the client to defecate into a clean container is incorrect as it may introduce contaminants. Transferring the specimen to a sterile container is unnecessary and can increase the risk of contamination. Refrigerating the collected specimen is also not recommended as it may alter the sample and affect the test results.

4. A client has a new diagnosis of osteoarthritis and is being taught about dietary management. Which of the following statements should be included in the teaching?

• A. Increase your intake of calcium-rich foods.
• B. Avoid foods that are high in potassium.
• C. Increase your intake of vitamin D-rich foods.
• D. Avoid foods that are high in sodium.

Correct answer: C

Rationale: The correct statement to include in the teaching is to increase the intake of vitamin D-rich foods. Vitamin D helps improve calcium absorption, which is beneficial for bone health and may help alleviate symptoms of osteoarthritis. Option A is incorrect because while calcium is important for bone health, the focus should be on vitamin D for calcium absorption. Option B is incorrect as potassium is generally not restricted in osteoarthritis. Option D is also incorrect as sodium restriction is more relevant for conditions like hypertension or heart failure, not specifically for osteoarthritis.

5. A client has major fecal incontinence and reports irritation in the perianal area. Which of the following actions should the nurse take first?

• A. Apply a fecal collection system
• B. Apply a barrier cream
• C. Cleanse and dry the area
• D. Check the client's perineum

Correct answer: D

Rationale: When a client with major fecal incontinence reports irritation in the perianal area, the nurse's initial action should be to assess the client's perineum to gather more information. By checking the perineum, the nurse can identify the extent and nature of the irritation, allowing for appropriate interventions to be initiated. This assessment is crucial in developing a comprehensive care plan and addressing the client's immediate needs effectively. Applying the nursing process priority-setting framework helps in planning care and prioritizing nursing actions, making assessment the initial step in this scenario. Applying a fecal collection system (choice A) would be premature without assessing the perineal area first. Similarly, applying a barrier cream (choice B) or cleansing and drying the area (choice C) should follow the assessment to ensure appropriate interventions are chosen based on the assessment findings.

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