Nursing Elites

1. What are the priority nursing assessments for a patient who has just undergone major surgery?

• A. Providing analgesia as prescribed
• B. Monitoring for signs of infection
• C. Assessing the surgical site for bleeding
• D. Monitoring the patient's vital signs

Correct answer: B

Rationale: The correct answer is to monitor for signs of infection. After major surgery, one of the priority nursing assessments is to watch for signs of infection, such as increased temperature, redness, swelling, or drainage at the surgical site. While providing analgesia is important for pain management, monitoring for infection takes precedence as it can lead to severe complications if not detected early. Assessing the surgical site for bleeding is crucial but is usually more relevant immediately after surgery. Monitoring the patient's vital signs is essential, but the specific focus on infection assessment is crucial in the immediate postoperative period.

2. A client with a new prescription for levothyroxine is receiving teaching from a nurse. Which statement indicates understanding of the teaching?

• A. I should take this with food
• B. I will see immediate results
• C. I might not realize the full effect of the medication for several weeks
• D. I should stop if I feel better

Correct answer: C

Rationale: The correct answer is C: 'I might not realize the full effect of the medication for several weeks.' Levothyroxine is a medication that may take several weeks for the full effect to be evident. Choice A is incorrect because levothyroxine should be taken on an empty stomach. Choice B is incorrect because immediate results are not expected with levothyroxine. Choice D is incorrect because stopping the medication without consulting a healthcare provider can be harmful, even if the client feels better.

3. A client who is 97 years old has successfully been treated for heart failure and is found not breathing. There is no DNR order in place. What should the nurse do?

• A. Notify the family and await further instructions.
• B. Initiate CPR and call for emergency assistance.
• C. Allow the family to make decisions about care.
• D. Follow the family's wishes and perform no interventions.

Correct answer: B

Rationale: In this scenario, with no DNR order in place and the client not breathing, the nurse should initiate CPR and call for emergency assistance. Option A is incorrect as immediate action is required in the absence of breathing. Option C is incorrect as the nurse should act promptly to provide life-saving measures. Option D is incorrect because the nurse's primary duty is to provide care in the absence of a directive preventing intervention.

4. What is the most appropriate method for preventing catheter-associated urinary tract infections (CAUTIs)?

• A. Insert a urinary catheter using clean gloves.
• B. Limit the duration of catheter use.
• C. Use a smaller size catheter to prevent trauma.
• D. Change the catheter tubing every 24 hours.

Correct answer: B

Rationale: The correct answer is B: Limit the duration of catheter use. Limiting the duration of catheterization is a crucial method for preventing catheter-associated urinary tract infections (CAUTIs). Prolonged catheter use increases the risk of introducing pathogens into the urinary tract, leading to infections. Using clean gloves for insertion (choice A) is important for preventing contamination but does not address the main cause of CAUTIs. Using a smaller size catheter (choice C) may help reduce trauma but does not directly prevent infections. Changing the catheter tubing every 24 hours (choice D) is not necessary unless clinically indicated, and it is not the most effective method for preventing CAUTIs.

5. When the nurse discovers a patient on the floor, and the patient states, 'I fell out of bed,' the nurse assesses the patient and then places the patient back in bed. What action should the nurse take next?

• A. Re-assess the patient.
• B. Complete an incident report.
• C. Notify the healthcare provider.
• D. Do nothing, as no harm has occurred.

Correct answer: C

Rationale: After a patient has fallen, it is crucial to notify the healthcare provider. The provider needs to be informed so that further assessment, evaluation, or intervention can be carried out to ensure the patient's safety and well-being. Re-assessing the patient (Choice A) is important but notifying the healthcare provider takes precedence. Completing an incident report (Choice B) is necessary but should follow notifying the healthcare provider. Doing nothing (Choice D) is not appropriate as patient safety and potential underlying issues need to be addressed promptly.

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