Nursing Elites

1. The patient had a CVA and developed right-sided hemiplegia. Which action is least appropriate for the nurse to take?

• A. Performing ROM exercises during bathing.
• B. Changing the patient's position every two hours.
• C. Suctioning the patient supine and tightly pulling the bed sheets across their feet.
• D. Placing the patient in the prone position for one hour three times a day.

Correct answer: C

Rationale: Suctioning the patient in a supine position and pulling the bed sheets tightly across their feet can lead to foot drop, which is harmful for a patient with right-sided hemiplegia. This action can exacerbate muscle weakness and impair circulation in the affected limb. It is crucial to avoid actions that may compromise the patient's safety and well-being, such as causing foot drop in this scenario.

2. The healthcare provider is assessing a client with a diagnosis of pneumonia. Which assessment finding is most concerning?

• A. Coarse crackles in the lungs.
• B. Fever of 101.2°F (38.4°C).
• C. Productive cough with yellow sputum.
• D. Respiratory rate of 28 breaths per minute.

Correct answer: D

Rationale: A respiratory rate of 28 breaths per minute (D) is most concerning because it indicates respiratory distress and requires immediate intervention. While coarse crackles (A), fever (B), and productive cough (C) are common findings in pneumonia, a high respiratory rate signifies a more severe condition that needs prompt attention to prevent respiratory failure. Monitoring the respiratory rate is crucial in assessing the severity of respiratory distress in pneumonia, as it can rapidly progress to respiratory failure if not managed promptly.

3. When planning care for a client with an indwelling urinary catheter, which nursing diagnosis has the highest priority?

• A. Self-care deficit
• B. Functional incontinence
• C. Fluid volume deficit
• D. High risk for infection

Correct answer: D

Rationale: The highest priority nursing diagnosis when planning care for a client with an indwelling urinary catheter is 'High risk for infection.' Indwelling urinary catheters pose a significant risk of infection due to their direct contact with the urinary system. Preventing and managing infections is crucial in the care of these clients. Monitoring for signs of infection, following proper catheter care protocols, and maintaining aseptic technique during catheter maintenance are essential steps to prevent complications associated with catheter-related infections. Choices A, B, and C are not the highest priority because in this case, the immediate concern is the risk of infection associated with the presence of the urinary catheter. While self-care deficit, functional incontinence, and fluid volume deficit are important considerations in overall patient care, they are not as critical as preventing potentially serious infections related to the indwelling urinary catheter.

4. Which serum laboratory value should the nurse monitor carefully for a client who has had an NG tube for suctioning for the past week?

• A. White blood cell count
• B. Albumin
• C. Calcium
• D. Sodium

Correct answer: D

Rationale: The nurse should carefully monitor serum sodium levels for a client with an NG tube on suction for an extended period due to potential fluid loss and the risk of developing hyponatremia, an electrolyte imbalance. Hyponatremia can occur as a result of continual suctioning leading to fluid loss, making it crucial to monitor sodium levels to prevent complications associated with low sodium levels. Monitoring white blood cell count, albumin, or calcium is not directly related to the impact of NG tube suction on fluid and electrolyte balance, so these values are not the priority in this scenario.

5. A male client presents to the clinic stating that he has a high-stress job and is having difficulty falling asleep at night. The client reports having a constant headache and is seeking medication to help him sleep. Which intervention should the nurse implement?

• A. Determine the client’s sleep and activity pattern
• B. Obtain a prescription for the client to take when stressed
• C. Refer the client for a sleep study and neurological follow-up
• D. Teach coping strategies to use when feeling stressed

Correct answer: D

Rationale: Teaching coping strategies is an appropriate first intervention for a client experiencing sleep difficulties and stress. It can help manage stress and improve sleep without immediately resorting to medication. By teaching coping strategies, the nurse empowers the client to address the underlying issues contributing to his sleep problems rather than just providing a temporary solution. Referring for a sleep study and neurological follow-up may be considered later if the client's sleep issues persist despite implementing coping strategies. Determining the client’s sleep and activity pattern may be helpful but addressing coping strategies is more beneficial in managing stress-related sleep issues. Obtaining a prescription for the client to take when stressed does not address the root cause of the sleep problem and may lead to dependency on medication rather than promoting long-term solutions.

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