Nursing Elites

1. 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.

2. A high school senior is complaining of a persistent cough and admits to smoking 10 to 15 cigarettes daily for the past year. He is convinced that he is hopelessly addicted to tobacco since he tried unsuccessfully to quit smoking last week. Which intervention is best for the nurse to implement?

• A. Encourage the student to associate with non-smokers only while attempting to stop smoking.
• B. Tell the student that he is still young and should continue trying various smoking cessation methods.
• C. Describe cigarette smoking as a habit that requires a strong will to overcome its addictiveness.
• D. Provide the student with the latest research data describing the long-term effects of tobacco use.

Correct answer: A

Rationale: Adolescents are particularly influenced by peers, so associating with non-smokers may help the student quit smoking. By being surrounded by non-smokers, the student is less likely to feel pressured to smoke and may be encouraged to adopt healthier behaviors. This intervention leverages the power of social influence to support smoking cessation efforts and create a more conducive environment for the student to quit smoking. Choices B, C, and D do not address the social aspect of smoking behavior and the influence of peers on smoking habits, making them less effective interventions in this case.

3. A client with chronic renal failure is receiving epoetin alfa (Epogen). Which laboratory test should the nurse monitor to evaluate the effectiveness of this medication?

• A. White blood cell count.
• B. Hemoglobin and hematocrit.
• C. Platelet count.
• D. Blood urea nitrogen (BUN) and creatinine.

Correct answer: B

Rationale: The correct answer is B: Hemoglobin and hematocrit. These are the primary laboratory tests to monitor the effectiveness of epoetin alfa (Epogen) in treating anemia. White blood cell count (A), platelet count (C), and blood urea nitrogen (BUN) and creatinine (D) are not directly related to the effects of this medication. Epoetin alfa stimulates the production of red blood cells, so monitoring hemoglobin and hematocrit levels helps assess the response to the treatment.

4. A client is admitted with a diagnosis of chronic obstructive pulmonary disease (COPD) exacerbation. Which intervention should the nurse implement first?

• A. Administer bronchodilators as prescribed.
• B. Administer oxygen via nasal cannula.
• C. Encourage the client to cough and deep breathe.
• D. Position the client in high Fowler's position.

Correct answer: B

Rationale: Administering oxygen via nasal cannula (B) is the priority intervention for a client with COPD exacerbation to improve oxygenation. In COPD exacerbation, there is impaired gas exchange leading to hypoxemia, making oxygen therapy the initial priority. Administering bronchodilators (A) helps with bronchodilation but should come after ensuring adequate oxygenation. Encouraging coughing and deep breathing (C) and positioning the client in high Fowler's position (D) are also beneficial interventions, but the first step is to address the oxygenation needs of the client.

5. The healthcare professional is using the Glasgow Coma Scale to perform a neurologic assessment. A comatose client winces and pulls away from a painful stimulus. What action should the healthcare professional take next?

• A. Document that the client responds to a painful stimulus.
• B. Observe the client's response to verbal stimulation.
• C. Place the client on seizure precautions for 24 hours.
• D. Report decorticate posturing to the healthcare provider.

Correct answer: A

Rationale: The client's response to a painful stimulus indicates a purposeful reaction, which should be accurately documented as per the assessment findings. This documentation is essential for ongoing monitoring and communication of the client's condition to the healthcare team.

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