Nursing Elites

1. 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.

2. When assisting a client with right-sided hemiplegia to get into a wheelchair, how should the nurse position the wheelchair?

• A. On the left side of the bed facing the foot of the bed.
• B. On the right side of the bed facing the head of the bed.
• C. Perpendicular to the bed on the right side.
• D. Facing the bed on the left side of the bed.

Correct answer: A

Rationale: Positioning the wheelchair on the left side of the bed facing the foot of the bed is the correct approach when assisting a client with right-sided hemiplegia. Placing the wheelchair on the left side allows the client to stand on their unaffected foot and pivot to sit down safely. This positioning facilitates a smoother transfer and helps maintain the client's stability during the process. Choice B is incorrect because positioning the wheelchair on the right side facing the head of the bed would make it challenging for the client to transfer due to their right-sided hemiplegia. Choice C is incorrect as placing the wheelchair perpendicular to the bed on the right side may not provide the necessary space and angle for a safe transfer. Choice D is incorrect as facing the bed on the left side of the bed does not provide the optimal position for the client to transfer from the bed to the wheelchair effectively.

3. The client with chronic obstructive pulmonary disease (COPD) is being taught pursed-lip breathing by the nurse. What is the purpose of this technique?

• A. To promote oxygenation by removing secretions.
• B. To reduce the amount of air trapped in the lungs.
• C. To increase the amount of carbon dioxide exhaled.
• D. To slow the respiratory rate and improve air exchange.

Correct answer: C

Rationale: Pursed-lip breathing is used to increase the amount of carbon dioxide exhaled (C) in clients with chronic obstructive pulmonary disease (COPD). By doing so, it helps prevent air trapping and enhances gas exchange, ultimately improving respiratory efficiency. While removing secretions (A) and reducing air trapping (B) can be associated benefits to some extent, the primary goal of pursed-lip breathing is to optimize carbon dioxide elimination and enhance breathing mechanics. Slowing the respiratory rate (D) is not the primary purpose of pursed-lip breathing.

4. During a sterile procedure at a client's bedside, a healthcare provider contaminates a sterile glove and the sterile field. What is the best action for the nurse to implement?

• A. Report the incident to the supervisor for aseptic technique violation.
• B. Allow the completion of the procedure.
• C. Inquire about the contamination of the glove and sterile field.
• D. Identify the breach in surgical asepsis and provide a new set of sterile supplies.

Correct answer: D

Rationale: In the scenario where a healthcare provider contaminates a sterile glove and the sterile field during a procedure, it is crucial to identify any breach in surgical asepsis. Any potential contamination should be considered compromised, and the nurse must act promptly to maintain sterility by providing a fresh set of sterile supplies for the procedure to continue safely.

5. A client with rheumatoid arthritis is experiencing chronic pain in both hands and wrists. Which information about the client is most important for the nurse to obtain when planning care?

• A. Amount of support provided by family members
• B. Measurement of pain using a scale of 0 to 10
• C. The ability to perform ADLs
• D. Nonverbal behaviors exhibited when pain occurs

Correct answer: C

Rationale: Assessing the client's ability to perform activities of daily living (ADLs) is crucial in planning care for someone with chronic pain. Understanding the client's functional status helps the nurse tailor interventions to promote independence and enhance quality of life. It provides valuable insight into the impact of pain on daily activities and guides the development of a comprehensive care plan to address the client's specific needs. While family support, pain measurement, and nonverbal behaviors are important aspects to consider in caring for a client with chronic pain, the ability to perform ADLs directly reflects the client's independence and quality of life, making it the most crucial information to obtain.

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