Nursing Elites

1. How should the nurse prepare the body of a deceased adult for transfer to the mortuary?

• A. Leave the body as is, no preparation needed
• B. Bathe the body and place ID tags on it
• C. Remove dentures before bathing the body
• D. Position the body with its head down and arms folded on its chest

Correct answer: B

Rationale: When preparing the body of a deceased adult for transfer to the mortuary, it is essential to bathe the body and place identification tags on it. This process ensures proper identification and respectful care of the deceased individual.

2. Prior to Mr. Landon undergoing a tracheostomy, what is the top nursing priority?

• A. Shaving the neck.
• B. Establishing a means of communication.
• C. Inserting a Foley catheter.
• D. Starting an IV.

Correct answer: B

Rationale: Before Mr. Landon undergoes a tracheostomy, the top nursing priority is to establish a means of communication. This is essential to ensure that Mr. Landon can effectively communicate his needs during and after the procedure. Shaving the neck (Choice A) may be necessary for the tracheostomy but is not the top priority. Inserting a Foley catheter (Choice C) and starting an IV (Choice D) are important nursing interventions but are not the priority before a tracheostomy procedure, where communication is key for patient safety and comfort.

3. The client with chronic obstructive pulmonary disease (COPD) is receiving oxygen therapy. Which intervention should the nurse implement to ensure the client’s safety?

• A. Encourage the client to use oxygen continuously
• B. Monitor the client’s respiratory rate and effort
• C. Set the oxygen flow rate at 6 liters per minute
• D. Teach the client to avoid wearing wool blankets

Correct answer: B

Rationale: Monitoring the client’s respiratory rate and effort is essential to evaluate the effectiveness of oxygen therapy and prevent complications such as respiratory depression. This intervention helps the nurse promptly detect any deterioration in the client's respiratory status and take necessary actions to ensure the client's safety. Encouraging continuous oxygen use (Choice A) may lead to oxygen toxicity. Setting the oxygen flow rate at a specific level (Choice C) without individual assessment can be inappropriate and potentially harmful. Teaching the client to avoid wearing wool blankets (Choice D) is unrelated to the safe use of oxygen therapy.

4. When emptying 350 mL of pale yellow urine from a client's urinal, the nurse notes that this is the first time the client has voided in 4 hours. Which action should the nurse take next?

• A. Record the amount on the client's fluid output record.
• B. Encourage the client to increase oral fluid intake.
• C. Notify the healthcare provider of the findings.
• D. Palpate the client's bladder for distention.

Correct answer: A

Rationale: The nurse should record the amount on the client's fluid output record because the 350 mL of pale yellow urine is a normal finding. This indicates appropriate urine output, so encouraging increased fluid intake or notifying the healthcare provider is not necessary at this time. Additionally, palpating the client's bladder for distention is not indicated based on the normal urine output observed.

5. The nurse-manager of a skilled nursing (chronic care) unit is instructing UAPs on ways to prevent complications of immobility. Which intervention should be included in this instruction?

• A. Perform range-of-motion exercises to prevent contractures.
• B. Decrease the client's fluid intake to prevent diarrhea.
• C. Massage the client's legs to reduce the occurrence of embolisms.
• D. Turn the client from side to back every shift.

Correct answer: A

Rationale: Performing range-of-motion exercises is essential in preventing contractures, which are common complications of immobility. These exercises help maintain joint flexibility and muscle strength, reducing the risk of contractures that can lead to functional limitations or pain for the client. Choices B, C, and D are incorrect. Decreasing fluid intake does not prevent immobility complications, but it can lead to dehydration. Massaging the client's legs does not directly address the prevention of immobility complications like contractures. Turning the client from side to back every shift is important for preventing pressure ulcers but does not directly address complications of immobility like contractures.

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