Nursing Elites

1. When caring for a client in hemorrhagic shock, how should the nurse position the client?

• A. Flat in bed with legs elevated.
• B. Flat in bed.
• C. Trendelenburg position.
• D. Semi-Fowler's position.

Correct answer: A

Rationale: When caring for a client in hemorrhagic shock, the nurse should position the client flat in bed with legs elevated. Elevating the legs helps increase venous return to the heart, aiding in the management of hemorrhagic shock by maintaining perfusion to vital organs.

2. What action should the nurse take after applying gloves to irrigate a client's indwelling urinary catheter using an open technique?

• A. Empty the client's urinary drainage bag.
• B. Draw up the irrigating solution into the syringe.
• C. Secure the client's catheter to the drainage tubing.
• D. Use aseptic technique to instill the irrigating solution.

Correct answer: B

Rationale: After applying gloves to irrigate an indwelling urinary catheter using an open technique, the next step for the nurse is to draw up the irrigating solution into the syringe. This step is crucial as it ensures that the solution is ready to be instilled through the catheter to maintain its patency and prevent blockages. Option A is incorrect as emptying the client's urinary drainage bag is not the immediate next step in the irrigation process. Option C is incorrect as securing the client's catheter to the drainage tubing is not necessary at this stage. Option D is incorrect as the question pertains to the action immediately after applying gloves and does not involve instilling the irrigating solution yet.

3. When bathing an uncircumcised boy older than 3 years, which action should the nurse take?

• A. Remind the child to clean his genital area.
• B. Defer perineal care due to the child's age.
• C. Retract the foreskin gently to cleanse the penis.
• D. Inquire about the reason for the child not being circumcised.

Correct answer: C

Rationale: The correct action when bathing an uncircumcised boy older than 3 years is to gently retract the foreskin to cleanse the penis. This is important to ensure proper hygiene and prevent the accumulation of bacteria that can lead to infections. It is not advisable to defer perineal care because of the child's age, as hygiene is crucial at any age. Asking the parents about the circumcision status may not be relevant during routine perineal care. Reminding the child to clean his genital area is not as effective as directly cleaning the area during bathing.

4. A client is receiving total parenteral nutrition (TPN). Which assessment finding is most concerning to the nurse?

• A. Blood glucose level of 150 mg/dL.
• B. Blood pressure of 110/70 mm Hg.
• C. Serum albumin level of 3.5 g/dL.
• D. The client's temperature is 100.4°F (38°C).

Correct answer: D

Rationale: A temperature of 100.4°F (38°C) (D) is the most concerning finding for a client receiving total parenteral nutrition (TPN) as it may indicate an infection, which poses a significant risk. Monitoring blood glucose level (A), blood pressure (B), and serum albumin (C) are also important, but an elevated temperature suggests a potential serious complication that requires immediate attention.

5. The healthcare provider who is preparing to give an adolescent client a prescribed antipsychotic medication notes that parental consent has not been obtained. Which action should the provider take?

• A. Review the chart for a signed consent for medication administration.
• B. Obtain parental consent before giving the medication.
• C. Do not give the medication and document the reason.
• D. Complete an incident report and notify the adolescent.

Correct answer: C

Rationale: The correct action is for the provider not to administer the medication and to document the reason. In the case of a minor, parental consent is required for medical treatment, including medication administration. It is important to follow legal and ethical guidelines to ensure the adolescent's well-being and rights are protected. Choice A is incorrect because simply reviewing the chart does not address the lack of parental consent. Choice B is incorrect as obtaining parental consent should be done before medication administration. Choice D is incorrect as notifying the adolescent is not the appropriate action in this situation, as parental consent is legally required for a minor's medical treatment.

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