Nursing Elites

1. The nurse determines that a postoperative client's respiratory rate has increased from 18 to 24 breaths/min. Based on this assessment finding, which intervention is most important for the nurse to implement?

• A. Encourage the client to increase ambulation in the room.
• B. Offer the client a high-carbohydrate snack for energy.
• C. Force fluids to thin the client's pulmonary secretions.
• D. Determine if pain is causing the client's tachypnea.

Correct answer: D

Rationale: An increased respiratory rate can be a sign of various issues postoperatively, including pain. Assessing and managing pain is crucial as it can lead to tachypnea. Pain, anxiety, and fluid accumulation in the lungs can all contribute to an increased respiratory rate. Therefore, determining if pain is causing the tachypnea is the most important intervention to address the underlying cause. Encouraging ambulation, offering snacks, or forcing fluids are not the priority in this situation as pain assessment takes precedence in managing the increased respiratory rate.

2. A policy requiring the removal of acrylic nails by all nursing personnel was implemented 6 months ago. Which assessment measure best determines if the intended outcome of the policy is being achieved?

• A. Number of staff-induced injuries
• B. Client satisfaction survey
• C. Healthcare-associated infection rate
• D. Rate of needle-stick injuries by nurses

Correct answer: C

Rationale: The correct answer is C - Healthcare-associated infection rate. Acrylic nails can harbor bacteria, increasing the risk of healthcare-associated infections. By implementing a policy to remove acrylic nails, the goal is to reduce the infection rate. Monitoring the healthcare-associated infection rate will provide a direct measure of the policy's effectiveness in achieving its intended outcome. This measure is more specific and directly related to the objective of reducing the risk of infections compared to the other choices.

3. The healthcare provider receives a report that a client with an indwelling urinary catheter has an output of 150 mL for the previous 6-hour shift. Which intervention should the healthcare provider implement first?

• A. Check the drainage tubing for a kink
• B. Review the intake and output record
• C. Notify the healthcare provider
• D. Give the client 8 oz of water to drink

Correct answer: A

Rationale: The first intervention should be to check the drainage tubing for a kink. This step is crucial as any kinks in the tubing could obstruct urine flow, leading to a decreased output. By ensuring the tubing is free from any obstructions, the healthcare provider can address a potential mechanical issue causing the low output before considering other interventions. Reviewing the intake and output record may provide valuable information but should come after ensuring the tubing is clear. Notifying the healthcare provider can be done later if needed, but the immediate concern is to check for any obstructions. Giving the client water to drink may be necessary depending on the assessment findings, but addressing a possible kink in the tubing takes precedence.

4. When discussing dietary preferences with a client adhering to a vegan diet, which dietary supplement should the nurse encourage the client to include in the dietary plan?

• A. Fiber
• B. Folate
• C. Ascorbic acid
• D. Vitamin B12

Correct answer: D

Rationale: Vitamin B12 is an essential nutrient predominantly found in animal products. Individuals following a vegan diet, which excludes animal products, are at a higher risk of vitamin B12 deficiency. Encouraging the client to include a vitamin B12 supplement in their dietary plan is crucial to prevent deficiency-related health issues. Choices A, B, and C are not specific to addressing the deficiency that vegan diets may cause. Fiber, folate, and ascorbic acid are important but do not directly address the risk of vitamin B12 deficiency in vegan diets.

5. A client who has a body mass index (BMI) of 30 is requesting information on the initial approach to a weight loss plan. Which action should the nurse recommend first?

• A. Plan low carbohydrate and high protein meals
• B. Engage in strenuous activity for an hour daily
• C. Keep a record of food and drinks consumed daily
• D. Participate in a group exercise class 3 times a week

Correct answer: C

Rationale: Keeping a food diary is a good first step to understand eating habits before making any dietary or activity changes.

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