Nursing Elites

1. A nurse has an order to remove sutures from a client. After retrieving the suture remover kit and applying sterile gloves, which of the following actions should the nurse take next?

• A. Clean sutures along the incision site.
• B. Grasp the knot of the sutures with forceps.
• C. Cut the sutures close to the skin on one side.
• D. Pull out the sutures with forceps in one piece.

Correct answer: A

Rationale: The correct action for the nurse to take next after preparing the suture remover kit and applying sterile gloves is to clean sutures along the incision site. This step is crucial in preventing infection, which is the greatest risk to the client during suture removal. Cleaning the site helps minimize the risk of introducing microorganisms into the incision, reducing the chances of infection. Grasping at the knot of the sutures with forceps (Choice B) is incorrect as it does not address the need to clean the incision. Cutting the sutures close to the skin on one side (Choice C) or pulling out the sutures with forceps in one piece (Choice D) without proper cleaning can increase the risk of infection and should not be the next step in the process of suture removal.

2. When documenting client care, which of the following abbreviations should be used?

• A. SS for sliding scale
• B. BRP for bathroom privileges
• C. OJ for orange juice
• D. SQ for subcutaneous

Correct answer: B

Rationale: When documenting client care, it is crucial to use standardized abbreviations to ensure clear communication and prevent misunderstandings. BRP for bathroom privileges is a recognized and commonly used abbreviation in healthcare settings. Choice A, SS for sliding scale, is not a standard abbreviation and can lead to confusion as it could be mistaken for other meanings. Choice C, OJ for orange juice, is informal and may not be universally understood in a healthcare context. Choice D, SQ for subcutaneous, is a valid abbreviation but may not be as relevant in the context of documenting client care compared to BRP, which is more specific and widely accepted.

3. A client is about to undergo emergency abdominal surgery for appendicitis. A healthcare professional is demonstrating postoperative deep breathing and coughing exercises to the client. The healthcare professional realizes the client may be unprepared to learn if the client:

• A. Is not feeling well
• B. Reports severe pain
• C. Has low blood pressure
• D. Is anxious

Correct answer: B

Rationale: Severe pain can be a significant distraction and impediment to the learning process. When a client is experiencing severe pain, their focus and attention are primarily directed towards managing the pain, making it difficult for them to absorb and retain new information effectively. Options A, C, and D, although important considerations in a healthcare setting, do not directly impact the client’s ability to learn in the same way that severe pain does. Not feeling well, low blood pressure, and anxiety are all factors that can be addressed or managed to facilitate learning, unlike severe pain which can significantly hinder the learning process.

4. A client with a history of heart failure presents to the clinic with a 2-day history of weight gain, swelling in the legs, and shortness of breath. Which of the following is the most appropriate initial nursing action?

• A. Perform a physical assessment
• B. Review the client's medication list
• C. Instruct the client to elevate the legs
• D. Obtain a detailed dietary history

Correct answer: A

Rationale: Performing a physical assessment is the most appropriate initial nursing action in this scenario. A thorough physical assessment helps evaluate the client's current condition, severity of symptoms, and identify any immediate concerns. This assessment can provide crucial information to guide further interventions and treatment. Reviewing the client's medication list (choice B) is important but may not address the immediate need for assessing the client's current status. Instructing the client to elevate the legs (choice C) may be beneficial but should come after a thorough assessment. Obtaining a detailed dietary history (choice D) is relevant for heart failure management but is not the most urgent initial action when the client presents with acute symptoms like weight gain, leg swelling, and shortness of breath.

5. Which statement by the nurse indicates culturally responsive care for a client following Islamic practices?

• A. “I will make sure the menu includes halal options.”
• B. “I will ask the client if they want to schedule prayer times during the day.”
• C. “I will avoid discussing care when the client’s family is around.”
• D. “I will make sure daily communion is available for this client.”

Correct answer: B

Rationale: The correct answer is B. Asking the client if they want to schedule prayer times during the day demonstrates respect and consideration for Islamic practices. Providing halal options (choice A) is important for dietary requirements in Islam, but it may not address the client's spiritual needs. Avoiding discussing care in front of the client's family (choice C) is not directly linked to Islamic practices and may not necessarily enhance cultural responsiveness. Offering daily communion (choice D) is associated with Christian religious practices, not Islamic practices, and may not meet the client's religious needs.

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