Nursing Elites

1. A client reports having insomnia. Which of the following interventions is appropriate for the nurse to recommend?

• A. Exercise 1 hour before bedtime.
• B. Eat a light carbohydrate snack before bedtime.
• C. Drink a cup of hot cocoa before bedtime.
• D. Take a 30-minute nap daily.

Correct answer: B

Rationale: Eating a light carbohydrate snack before bedtime is a suitable intervention for insomnia because it can help stabilize blood sugar levels and promote sleep. Exercising close to bedtime may actually disrupt sleep patterns due to increased alertness and body temperature. Drinking hot cocoa before bedtime, which contains caffeine, may interfere with falling asleep. Taking a nap during the day can make it harder to fall asleep at night and may worsen insomnia. Therefore, the best recommendation among the choices provided is to eat a light carbohydrate snack before bedtime.

2. During an abdominal examination, a nurse in a provider’s office determines that a client has abdominal distention. The protrusion is at midline, the skin over the area is taut, and the nurse notes no involvement of the flanks. Which of the following possible causes of distention should the nurse suspect?

• A. Fat
• B. Fluid
• C. Flatus
• D. Hernias

Correct answer: D

Rationale: The correct answer is 'Hernias.' Abdominal distention with a midline protrusion, taut skin, and no involvement of the flanks is characteristic of hernias. Hernias are caused by a weakness in the abdominal wall, allowing organs or tissues to protrude through. Fluid accumulation (ascites) typically presents with a more generalized distention, while fat accumulation may cause more diffuse distension rather than a focal midline protrusion. Flatus, or gas, would not typically present with a visible midline protrusion and taut skin like hernias.

3. Before donning gloves to perform a procedure, proper hand hygiene is essential. The healthcare professional understands that the most important aspect of hand hygiene is the amount of:

• A. Temperature
• B. Time
• C. Friction
• D. Soap

Correct answer: C

Rationale: The correct answer is C: Friction. The amount of friction is crucial in effective hand hygiene to remove microorganisms. Rubbing hands together with friction helps to dislodge and remove dirt, oils, and microorganisms. While temperature and soap are important factors in hand hygiene, the mechanical action of friction plays a more significant role in physically removing contaminants. Time is also important in hand hygiene practice, but without adequate friction, the effectiveness of the process is compromised.

4. When planning home care for a 72-year-old client with osteomyelitis requiring a 6-week course of intravenous antibiotics, what is the most important action by the nurse?

• A. Investigating the client's insurance coverage for home IV antibiotic therapy
• B. Determining if there are adequate hand washing facilities in the home
• C. Assessing the client's ability to participate in self-care and/or the reliability of a caregiver
• D. Selecting the appropriate venous access device

Correct answer: C

Rationale: Assessing the client's ability to participate in self-care or evaluating the reliability of a caregiver is crucial in ensuring adherence to the treatment plan. This action helps determine if the client can manage the intravenous antibiotics at home independently or if assistance is needed. Investigating insurance coverage, ensuring hand washing facilities, and selecting the venous access device are important aspects of care but assessing the client's ability for self-care and caregiver reliability takes precedence to promote treatment success and safety.

5. Before administering the prescribed morphine sulfate to a client post-op following laparotomy who reports pain and dry mouth, what should the nurse do first?

• A. Measure the client's vital signs.
• B. Assess the client's pain level.
• C. Verify the morphine order with another nurse.
• D. Check the client's last dose of morphine.

Correct answer: A

Rationale: Before administering morphine sulfate, it is crucial to measure the client's vital signs to ensure that the client is stable and safe to receive the medication. This step helps identify any contraindications or abnormalities that could affect the administration of morphine. Assessing the client's pain level (choice B) is important, but ensuring the client's physiological stability takes precedence. Verifying the morphine order with another nurse (choice C) and checking the client's last dose of morphine (choice D) are important steps but are not the priority before administering the medication.

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