Nursing Elites

1. A client who has an indwelling catheter reports a need to urinate. Which of the following actions should the nurse take?

• A. Check the catheter to see whether it is patent.
• B. Reassure the client that it is not possible for them to urinate.
• C. Re-catheterize the bladder with a larger-gauge catheter.
• D. Collect a urine specimen for analysis.

Correct answer: A

Rationale: When a client with an indwelling catheter reports a need to urinate, the nurse's initial action should be to check the catheter for patency. This is crucial to ensure that the catheter is not blocked, twisted, or kinked, which could lead to urinary retention. Reassuring the client without assessing the catheter could delay necessary interventions. Re-catheterizing the bladder with a larger-gauge catheter should not be the first step unless catheter patency is confirmed as an issue. Collecting a urine specimen for analysis is important but not the immediate priority when the client reports a need to urinate.

2. A client who requires maximal support is being taught how to use a two-wheeled walker by a nurse. Which of the following actions by the client indicates an understanding of the teaching?

• A. The client moves the walker ahead 25.4 cm with each step
• B. The client picks up the walker with each step
• C. The client stands with elbows slightly bent while holding the walker
• D. The client stoops slightly forward when moving the walker

Correct answer: C

Rationale: The correct answer is C. When using a two-wheeled walker, the client should stand with elbows slightly bent to maintain balance and stability. This position helps distribute weight effectively and promotes proper use of the walker. Choices A, B, and D are incorrect. Choice A does not demonstrate proper posture while using the walker. Choice B of picking up the walker with each step is not the correct technique and can lead to instability. Choice D of stooping slightly forward is also incorrect as it can affect balance and posture negatively.

3. When changing a client's colostomy pouch and noticing peristomal skin irritation, which of the following actions should the nurse take?

• A. Change the pouch as needed based on individual requirements.
• B. Apply the pouch only when the skin barrier is completely dry.
• C. Pat the peristomal skin dry after cleaning.
• D. Ensure the pouch is 0.32 cm (1/8 in) larger than the stoma.

Correct answer: D

Rationale: When a nurse observes peristomal skin irritation while changing a client's colostomy pouch, it is crucial to ensure that the pouch is slightly larger (0.32 cm or 1/8 inch) than the stoma. This extra space helps prevent the pouch from rubbing against the stoma and causing further irritation. Option A is correct because colostomy pouches should be changed based on individual needs, not necessarily every 24 hours. Option B is incorrect because applying the pouch only when the skin barrier is completely dry ensures better adhesion. Option C is incorrect as patting the peristomal skin dry after cleaning is more gentle and less likely to cause irritation compared to rubbing.

4. In an emergency situation, the charge nurse on the night shift at an urgent care center has to deal with admitting clients of higher acuity than usual due to a large fire in the area. Which style of leadership and decision-making would be best in this circumstance?

• A. Assume a decision-making role
• B. Seek input from staff
• C. Use a non-directive approach
• D. Shared decision-making with others

Correct answer: A

Rationale: In an emergency situation such as dealing with patients of higher acuity due to a large fire, it is crucial for the charge nurse to assume a decision-making role. This style of leadership allows for quick and efficient decision-making to manage the increased acuity of patients effectively. Seeking input from staff (Choice B) may delay critical decisions needed in emergencies. Using a non-directive approach (Choice C) or shared decision-making with others (Choice D) may not be suitable in urgent situations where immediate actions are required to address the high acuity of patients.

5. A client with a diagnosis of Guillain-Barre syndrome is in a non-responsive state, yet vital signs are stable and breathing is independent. What should the nurse document to most accurately describe the client's condition?

• A. Comatose, breathing unlabored
• B. Glasgow Coma Scale 8, respirations regular
• C. Appears to be sleeping, vital signs stable
• D. Glasgow Coma Scale 13, no ventilator required

Correct answer: B

Rationale: The correct answer is B. A Glasgow Coma Scale of 8 with regular respirations accurately describes a non-responsive state with independent breathing. Choice A is incorrect because 'comatose' implies a deeper state of unconsciousness than what is described in the scenario. Choice C is inaccurate as the client is not merely sleeping but non-responsive. Choice D is incorrect as a Glasgow Coma Scale of 13 indicates a higher level of consciousness than what is presented in the scenario.

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