Nursing Elites

1. An older adult client appears agitated when the nurse requests that the client’s dentures be removed prior to surgery and states, “I never go anywhere without my teeth.” Which of the following is an appropriate nursing response?

• A. You should comply with the request
• B. You seem worried. Are you concerned someone may see you without your teeth?
• C. I will call your family to discuss this
• D. It’s not a big deal; just remove them

Correct answer: B

Rationale: The appropriate nursing response in this situation is to acknowledge and address the client's concerns empathetically. By expressing understanding and asking if the client is worried about being seen without their teeth, the nurse shows empathy and attempts to alleviate the client's anxiety. Choice A is incorrect as it dismisses the client's feelings. Choice C is inappropriate as it does not directly address the client's agitation. Choice D is not the best response as it minimizes the client's feelings and does not provide emotional support.

2. When evaluating care of an immobilized patient, which action will the nurse take?

• A. Focus on whether the interdisciplinary team is satisfied with the care.
• B. Compare the patient's actual outcomes with the outcomes in the care plan.
• C. Involve primarily the patient's family and health care team to determine goal achievement.
• D. Use objective data solely in determining whether interventions have been successful.

Correct answer: B

Rationale: When evaluating the care of an immobilized patient, the nurse should focus on assessing outcomes and response to nursing care. By comparing the patient's actual outcomes with the outcomes identified during planning, the nurse can determine the effectiveness of the interventions implemented. This process allows for a comprehensive evaluation of the care provided. Choice A is incorrect because the satisfaction of the interdisciplinary team does not directly reflect the patient's outcomes and response to care. Choice C is incorrect as it mainly focuses on the involvement of the patient's family and healthcare team, which may not provide a holistic evaluation of the patient's care. Choice D is incorrect as relying solely on objective data may lead to overlooking important subjective aspects of the patient's response and outcomes, which are also crucial in evaluating care effectively.

3. A charge nurse is talking with a newly licensed nurse and is reviewing nursing interventions that do not require a provider’s prescription. Which of the following interventions should the charge nurse include?

• A. Writing a prescription for morphine sulfate as needed for pain
• B. Inserting a nasogastric (NG) tube to relieve gastric distention
• C. Showing a client how to use progressive muscle relaxation
• D. Performing a daily bath after the evening meal

Correct answer: C

Rationale: The correct answer is C. Showing a client how to use progressive muscle relaxation is an intervention that does not require a provider's prescription. This falls within the nurse's scope of practice and can be implemented to promote relaxation and reduce stress for the client. Choices A and B involve tasks that require a provider's prescription and specialized training. Writing a prescription for morphine sulfate and inserting an NG tube should only be done by authorized healthcare providers. Choice D, performing a daily bath, while within the nurse's scope, does not specifically address interventions that do not require a provider's prescription.

4. A client with moderate persistent asthma is admitted for a minor surgical procedure. On admission, the peak flow meter is measured at 480 liters/minute. Post-operatively, the client is complaining of chest tightness. The peak flow has dropped to 200 liters/minute. What should the nurse do first?

• A. Notify the healthcare provider
• B. Administer the PRN dose of Albuterol
• C. Apply oxygen at 2 liters per nasal cannula
• D. Repeat the peak flow reading in 30 minutes

Correct answer: B

Rationale: In a client with moderate persistent asthma experiencing a drop in peak flow and chest tightness post-operatively, the first action the nurse should take is to administer the PRN dose of Albuterol. Albuterol is a short-acting bronchodilator that helps relieve bronchospasm and improve breathing. Notifying the healthcare provider (choice A) can be done after initiating immediate treatment with Albuterol. Applying oxygen (choice C) may be necessary but addressing the bronchospasm with Albuterol is the priority. Repeating the peak flow reading (choice D) can be considered after administering Albuterol to assess the response to treatment.

5. What is the most important action for the nurse to take to prevent infection in a client who has just returned from surgery with an indwelling urinary catheter in place?

• A. Change the catheter every 72 hours.
• B. Ensure the catheter tubing is free of kinks.
• C. Clean the perineal area with antiseptic solution daily.
• D. Irrigate the catheter with normal saline every shift.

Correct answer: B

Rationale: The most important action to prevent infection in a client with an indwelling urinary catheter is to ensure the catheter tubing is free of kinks. This action helps prevent obstruction, ensures proper drainage, and reduces the risk of infection. Changing the catheter every 72 hours is not necessary unless clinically indicated and may introduce unnecessary risk. Cleaning the perineal area with antiseptic solution daily is important for general hygiene but not the most critical action for catheter-related infection prevention. Irrigating the catheter with normal saline every shift is not a routine nursing intervention for catheter care and may increase the risk of introducing pathogens.

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