Nursing Elites

1. A healthcare professional is preparing to inject heparin subcutaneously for a client who is postoperative. Which of the following actions should the healthcare professional take?

• A. Use a 25-gauge needle.
• B. Select a site on the client’s abdomen.
• C. Use the Z-track technique to displace the skin on the injection site.
• D. Observe for bleb formation to confirm proper placement.

Correct answer: B

Rationale: For subcutaneous injections like heparin, a 25-27 gauge needle is recommended, making choice A incorrect. The abdomen is a commonly used site for heparin injection due to its consistent absorption and convenience, making choice B the correct answer. The Z-track technique is not necessary for subcutaneous injections, making choice C unnecessary. Observing for bleb formation is not a standard practice for confirming proper placement of subcutaneous heparin, making choice D incorrect. Therefore, the correct action is to select a site on the client's abdomen for the injection.

2. A client diagnosed with a terminal illness asks the nurse about the nurse’s religious beliefs related to death and dying. An appropriate nursing response is to:

• A. Share personal beliefs
• B. Encourage the client to express their thoughts about death and dying
• C. Redirect the conversation to medical treatment
• D. Inform the client that the nurse’s beliefs are not relevant

Correct answer: B

Rationale: Encouraging the client to express their own thoughts about death and dying is an appropriate nursing response in this situation. It allows the client to explore and express their feelings, fears, and beliefs, facilitating a therapeutic conversation. Sharing personal beliefs (choice A) may not be appropriate as it could impose the nurse's beliefs on the client and hinder open discussion. Redirecting the conversation to medical treatment (choice C) may avoid addressing the client's emotional and spiritual needs. Informing the client that the nurse’s beliefs are not relevant (choice D) dismisses the client's concerns and does not encourage open communication.

3. A client is incontinent of loose stool and is reporting a painful perineum. Which of the following is the priority nursing action?

• A. Assess the client's perineum
• B. Administer pain medication
• C. Clean the area with a mild cleanser
• D. Apply a barrier cream to the affected area

Correct answer: A

Rationale: Assessing the client's perineum is the priority nursing action in this situation. By checking the perineum, the nurse can evaluate for skin damage, irritation, infection, or other issues that may be causing the client's pain. This assessment is crucial to determine the appropriate interventions needed to address the client's discomfort and prevent complications. Administering pain medication, cleaning the area with a mild cleanser, or applying a barrier cream are important interventions but should follow the initial assessment of the perineum to ensure comprehensive care and effective management of the client's condition. Prioritizing assessment allows for a targeted and individualized approach to care, enhancing the client's overall well-being.

4. A client returning from the surgical suite following a vaginal hysterectomy is awake and asking for something to drink. Her post-op diet prescription reads: 'clear liquids, advance diet as tolerated.' Which of the following is appropriate for the nurse to tell the patient?

• A. ''I am going to listen to your abdomen.''
• B. ''You need to wait until the surgeon evaluates your condition.''
• C. ''You can have clear liquids, but let me check with the surgeon first.''
• D. ''It is best to start with small sips of clear liquids and observe how you feel.''

Correct answer: A

Rationale: The correct answer is A: ''I am going to listen to your abdomen.'' Listening to the abdomen helps assess bowel sounds and ensure that the client’s gastrointestinal system is ready for oral intake. Choice B is incorrect because the client does not necessarily need to wait for the surgeon to evaluate before starting with clear liquids. Choice C is incorrect because unless there are specific contraindications, clear liquids are usually allowed after surgery. Choice D is incorrect as it does not address the immediate assessment needed before initiating oral intake post-operatively.

5. Why should a client with an ileal conduit be instructed to empty the collection device frequently?

• A. Force urine to back up into the kidneys.
• B. Suppress production of urine.
• C. Cause the device to pull away from the skin.
• D. Tear the ileal conduit

Correct answer: C

Rationale: A full urine collection bag can cause the device to pull away from the skin, leading to potential leakage and skin irritation. Choice A is incorrect because a full urine collection bag does not force urine to back up into the kidneys. Choice B is incorrect as a full collection bag does not suppress the production of urine. Choice D is incorrect as a full collection bag is unlikely to tear the ileal conduit.

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