Nursing Elites

1. The nurse is caring for a patient who needs to be placed in the prone position. Which action will the nurse take?

• A. Place a pillow under the patient's lower legs.
• B. Turn the head toward one side with a large, soft pillow.
• C. Position legs flat against the bed.
• D. Raise the head of the bed to 45 degrees.

Correct answer: A

Rationale: Placing a pillow under the patient's lower legs when in the prone position is essential to allow dorsiflexion of the ankles and some knee flexion, which promote relaxation. This position also helps in maintaining proper alignment of the spine. Options B, C, and D are incorrect because turning the head, positioning legs flat against the bed, and raising the head of the bed to 45 degrees are not appropriate actions for a patient in the prone position. Turning the head to one side with a large, soft pillow is commonly done for patients in the supine position to maintain proper alignment and airway patency. Positioning legs flat against the bed is more suitable for a patient in a supine or semi-fowler's position. Raising the head of the bed to 45 degrees is typically done for patients who need semi-fowler's positioning for respiratory support or to prevent aspiration.

2. A post-op nurse has an indwelling catheter in place for gravity drainage. The nurse notes that the client's urine bag has been empty for 2 hours. The first action the nurse should take is to:

• A. Check to see if the tubing is kinked.
• B. Increase the IV fluid rate.
• C. Check the catheter insertion site.
• D. Contact the healthcare provider.

Correct answer: A

Rationale: The correct action for the nurse to take when the urine bag has not filled for 2 hours is to check if the tubing is kinked. Kinks in the tubing can obstruct the flow of urine from the catheter, leading to decreased drainage. Increasing the IV fluid rate is not the appropriate initial action in this situation as the primary concern is with the catheter drainage. Checking the catheter insertion site would be secondary to ensuring proper drainage. Contacting the healthcare provider is not necessary as the issue can often be resolved by checking for simple tubing obstructions first.

3. A client with diabetes mellitus reports feeling anxious, shaky, and weak. These findings are manifestations of which of the following complications?

• A. Hyperglycemia
• B. Hypoglycemia
• C. Ketoacidosis
• D. Dawn phenomenon

Correct answer: B

Rationale: The correct answer is B, Hypoglycemia. In diabetes mellitus, hypoglycemia can lead to symptoms such as anxiety, shakiness, and weakness due to low blood sugar levels. Hyperglycemia (choice A) is high blood sugar levels and typically presents with symptoms like increased thirst and frequent urination. Ketoacidosis (choice C) is a serious complication of diabetes characterized by high levels of ketones in the blood, leading to symptoms such as fruity breath and rapid breathing. The Dawn phenomenon (choice D) refers to an abnormal early-morning increase in blood sugar levels without an associated hypoglycemia during the night.

4. A client is having difficulty breathing while laying in bed with a nasal cannula delivering oxygen. Which of the following interventions should the nurse take first?

• A. Suction the client's airway
• B. Administer a bronchodilator
• C. Increase the humidity in the client's room
• D. Assist the client to an upright position

Correct answer: D

Rationale: The correct answer is to assist the client to an upright position. When a client is having difficulty breathing, promoting optimal oxygenation is essential. Elevating the head of the bed improves ventilation and lung expansion by reducing pressure on the diaphragm. This position allows the lungs to expand fully, enhancing oxygen exchange. Suctioning the airway may be necessary if there are secretions causing obstruction, but it is not the first intervention in this scenario. Administering a bronchodilator is appropriate for bronchoconstriction but does not address the immediate need for better ventilation. Increasing humidity can be beneficial in certain respiratory conditions, but it is not the initial priority when a client is struggling to breathe.

5. A client is on bed rest. Which of the following interventions should the nurse plan to implement?

• A. Encourage the client to perform antiembolic exercises every 2 hours.
• B. Instruct the client to cough and deep breathe every 4 hours.
• C. Restrict the client’s fluid intake.
• D. Reposition the client every 4 hours.

Correct answer: A

Rationale: To prevent complications associated with prolonged bed rest, encouraging the client to perform antiembolic exercises every 2 hours is essential. These exercises help promote circulation and prevent blood clots. Instructing the client to cough and deep breathe every 4 hours is beneficial for respiratory function, but it is not as critical as antiembolic exercises. Repositioning the client every 4 hours helps prevent pressure ulcers and maintain skin integrity. Restricting fluid intake is not recommended, as hydration is important for overall health and well-being, especially for clients on bed rest.

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