Nursing Elites

1. A nurse enters a client's room and finds her on the floor. The client's roommate reports that the client was trying to get out of bed and fell over the bedrail onto the floor. Which of the following statements should the nurse document about this incident?

• A. Found on floor
• B. Client slipped while getting out of bed
• C. Patient fell while attempting to get out of bed
• D. Roommate reported fall

Correct answer: A

Rationale: The correct answer is 'A: Found on floor.' This choice provides a clear and objective account of the situation without adding interpretation or assumptions. It is crucial to document only the facts observed directly. Choices B and C introduce speculation by suggesting how the incident happened, which the nurse did not witness. Choice D is not directly related to the nurse’s observation and should not be documented as the primary incident.

2. Which of the following is the correct method to reduce the risk of infection when handling a urinary catheter?

• A. Clean the catheter tubing with soap and water.
• B. Maintain sterile technique when inserting the catheter.
• C. Insert the catheter using clean gloves and a clean technique.
• D. Flush the catheter tubing regularly with sterile water.

Correct answer: B

Rationale: The correct method to reduce the risk of infection when handling a urinary catheter is to maintain sterile technique when inserting the catheter. Sterile technique helps prevent introducing pathogens into the urinary system, reducing the risk of infection. Choice A is incorrect because cleaning the catheter tubing with soap and water is not sufficient for preventing infection. Choice C is incorrect as clean gloves and technique are not enough; sterile technique is necessary. Choice D is incorrect as flushing the catheter tubing with sterile water, though important for maintaining catheter patency, does not address the need for sterile technique during insertion to prevent infection.

3. Which intervention will best help a patient with chronic pain maintain mobility?

• A. Provide the patient with opioids to control pain.
• B. Encourage stretching exercises to improve flexibility.
• C. Teach the patient to use assistive devices like a cane.
• D. Recommend complete bed rest until the pain subsides.

Correct answer: B

Rationale: Encouraging stretching exercises is the most appropriate nursing intervention to help a patient with chronic pain maintain mobility. Stretching exercises can improve flexibility, prevent stiffness, and promote better range of motion in patients with chronic pain. Providing opioids (Choice A) may help control pain but does not directly address mobility. Teaching the patient to use assistive devices (Choice C) may be beneficial but does not focus on improving mobility directly. Recommending complete bed rest (Choice D) can lead to deconditioning and further loss of mobility, which is not recommended for chronic pain management.

4. A patient with chronic obstructive pulmonary disease (COPD) is being cared for by a nurse. What is the most appropriate action to improve the patient's oxygenation?

• A. Encourage the patient to use incentive spirometry.
• B. Administer oxygen via nasal cannula as prescribed.
• C. Assist the patient with coughing and deep breathing exercises.
• D. Position the patient in a high Fowler's position.

Correct answer: B

Rationale: Administering oxygen via nasal cannula as prescribed is the most appropriate action to improve the patient's oxygenation in COPD. Oxygen therapy helps maintain adequate oxygen levels in the blood, which is crucial for managing COPD. Encouraging the use of incentive spirometry, assisting with coughing and deep breathing exercises, and positioning the patient in high Fowler's position are all beneficial interventions, but administering oxygen is the priority for immediate oxygenation support in COPD.

5. Which intervention is most effective in preventing deep vein thrombosis (DVT) in a postoperative patient?

• A. Encourage the patient to drink plenty of fluids.
• B. Encourage early ambulation and leg exercises.
• C. Administer anticoagulants as prescribed.
• D. Apply compression stockings to the patient's legs.

Correct answer: B

Rationale: The most effective intervention in preventing deep vein thrombosis (DVT) in a postoperative patient is to encourage early ambulation and leg exercises. Early ambulation helps promote circulation, preventing stasis and reducing the risk of blood clot formation. Encouraging the patient to drink plenty of fluids (choice A) is important for overall health but is not the most effective intervention for preventing DVT. Administering anticoagulants (choice C) is a valuable intervention in some cases, but it may not be suitable for all postoperative patients. Applying compression stockings (choice D) can help prevent DVT but is generally not as effective as early ambulation and leg exercises in postoperative patients.

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