Nursing Elites

1. After surgery, a patient has decreased cardiac output. What is a likely observation by the nurse?

• A. Decreased urine output
• B. Increased urine output
• C. Flushing of the skin
• D. Hyperventilation

Correct answer: A

Rationale: A decrease in cardiac output can lead to decreased blood flow to the kidneys, resulting in decreased urine output. The kidneys rely on adequate blood supply to filter waste and produce urine. Therefore, a decreased urine output is a common observation when cardiac output is reduced. Choices B, C, and D are incorrect. Increased urine output is not typically associated with decreased cardiac output; flushing of the skin is more related to vasodilation, and hyperventilation is not directly linked to decreased cardiac output.

2. By rolling contaminated gloves inside-out, the healthcare professional is affecting which step in the chain of infection?

• A. Mode of transmission
• B. Portal of entry
• C. Reservoir
• D. Portal of exit

Correct answer: A

Rationale: When contaminated gloves are rolled inside-out, they are serving as a mode of transmission by carrying pathogens from the reservoir's portal of exit to a new portal of entry. This action increases the risk of transmitting infections from one person to another, emphasizing the importance of proper glove removal techniques to prevent the spread of pathogens. Choices B, C, and D are incorrect in this context. Portal of entry refers to the route through which a pathogen enters a susceptible host, reservoir is the habitat where the pathogen lives, grows, and multiplies, and portal of exit is the path through which a pathogen leaves its host.

3. A client with stage 4 lung cancer receiving in-home hospice care expresses concerns about pain while the nurse is arranging for discharge. What action should the nurse take?

• A. Explain the potential respiratory issues associated with morphine use.
• B. Educate the family on assessing the effectiveness of analgesics.
• C. Suggest requesting a patient-controlled analgesic (PCA) pump from the healthcare provider.
• D. Provide the client with a schedule for around-the-clock prescribed analgesic use.

Correct answer: D

Rationale: In managing pain for a client with stage 4 lung cancer in hospice care, providing a schedule for around-the-clock prescribed analgesic use is essential. This approach ensures continuous pain control and helps prevent breakthrough pain. By having a consistent dosing schedule, the client can maintain a more stable level of pain relief, enhancing their comfort and quality of life during this critical time.

4. A client with rheumatoid arthritis is experiencing chronic pain in both hands and wrists. Which information about the client is most important for the nurse to obtain when planning care?

• A. Amount of support provided by family members
• B. Measurement of pain using a scale of 0 to 10
• C. The ability to perform ADLs
• D. Nonverbal behaviors exhibited when pain occurs

Correct answer: C

Rationale: Assessing the client's ability to perform activities of daily living (ADLs) is crucial in planning care for someone with chronic pain. Understanding the client's functional status helps the nurse tailor interventions to promote independence and enhance quality of life. It provides valuable insight into the impact of pain on daily activities and guides the development of a comprehensive care plan to address the client's specific needs. While family support, pain measurement, and nonverbal behaviors are important aspects to consider in caring for a client with chronic pain, the ability to perform ADLs directly reflects the client's independence and quality of life, making it the most crucial information to obtain.

5. The UAP is positioning a newly admitted client with a seizure disorder in a supine position. The UAP is placing soft pillows along the side rails. What action should the nurse take?

• A. Instruct the UAP to obtain soft blankets to secure to the side rails instead of pillows
• B. Ensure that the UAP has placed pillows effectively to protect the client
• C. Ask the UAP to use some pillows to prop the client in a side-lying position
• D. Assume responsibility for placing the pillows while the UAP completes another task

Correct answer: A

Rationale: To prevent the risk of suffocation, soft blankets are preferred over pillows for padding side rails in clients with seizure disorders. Pillows can pose a suffocation hazard, especially during a seizure episode when the client's movements may be uncontrolled. Instructing the UAP to use soft blankets instead of pillows is crucial for ensuring the client's safety. Choice B is incorrect because pillows can be hazardous during a seizure. Choice C is incorrect as side-lying position may not be appropriate for a client with a seizure disorder. Choice D is incorrect as it does not address the safety concern related to using pillows.

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