Nursing Elites

1. A nurse is planning care for a client with thrombocytopenia. Which of the following actions should the nurse include?

• A. Encourage the client to floss daily.
• B. Remove fresh flowers from the client's room.
• C. Provide the client with a stool softener.
• D. Avoid serving raw vegetables.

Correct answer: C

Rationale: The correct answer is C: Provide the client with a stool softener. Thrombocytopenia is a condition characterized by a low platelet count, which can lead to an increased risk of bleeding. Providing the client with a stool softener is essential to prevent straining during bowel movements, which could result in bleeding for clients with thrombocytopenia. Encouraging the client to floss daily (choice A) is unrelated to the management of thrombocytopenia. Removing fresh flowers (choice B) is more relevant for clients with a compromised immune system. Avoiding serving raw vegetables (choice D) is important for clients with compromised immune systems to prevent foodborne illnesses, but it is not directly related to thrombocytopenia.

2. A nurse is preparing to insert an indwelling urinary catheter for a male client. Which of the following actions should the nurse take?

• A. Insert the catheter until urine flows, then advance 2.5 to 5 cm (1 to 2 in) further.
• B. Advance the catheter 7.5 to 10 cm (3 to 4 in) after urine begins to flow.
• C. Advance the catheter 17 to 22.5 cm (7 to 9 in) after urine begins to flow.
• D. Advance the catheter 5 to 7.5 cm (2 to 3 in) after urine begins to flow.

Correct answer: C

Rationale: When inserting an indwelling urinary catheter for a male client, it is crucial to advance the catheter 17 to 22.5 cm after urine begins to flow. This helps ensure proper placement in the male urethra, which is longer compared to females. Choice A is incorrect as advancing only 2.5 to 5 cm would not reach the correct placement in male clients. Choice B is incorrect as advancing 7.5 to 10 cm is insufficient to reach the appropriate location in male clients. Choice D is also incorrect as advancing 5 to 7.5 cm would likely not reach the desired placement in male clients.

3. A nurse is caring for a client who has a chest tube following thoracic surgery. Which of the following actions should the nurse take?

• A. Clamp the chest tube when assisting the client out of bed.
• B. Empty the drainage system every 8 hours.
• C. Keep the collection device below the client's chest.
• D. Strip the chest tube every 4 hours.

Correct answer: C

Rationale: The correct action for the nurse to take is to keep the collection device below the client's chest. This positioning ensures proper drainage of fluid from the chest, preventing backflow of fluids. Clamping the chest tube when assisting the client out of bed is incorrect as it can lead to fluid accumulation and potential complications. Emptying the drainage system every 8 hours is necessary but not the priority over maintaining proper positioning. Stripping the chest tube every 4 hours is an outdated practice and can cause damage to the tissue and should be avoided.

4. A nurse is reviewing the medical record of a client who is receiving morphine for pain management. Which of the following findings should the nurse report to the provider?

• A. Heart rate of 88/min
• B. Pain rating of 4 on a scale of 0 to 10
• C. Respiratory rate of 10/min
• D. Temperature of 37.2°C (99°F)

Correct answer: C

Rationale: The correct answer is C. A respiratory rate of 10/min indicates respiratory depression, a serious adverse effect of morphine that should be reported immediately. Options A, B, and D are within acceptable ranges and not indicative of life-threatening complications when administering morphine.

5. A nurse is caring for a client who is receiving oxytocin to augment labor. The client's contractions are occurring every 90 seconds with a duration of 90 seconds. Which of the following actions should the nurse take?

• A. Increase oxytocin infusion.
• B. Decrease oxytocin infusion.
• C. Maintain oxytocin infusion.
• D. Discontinue oxytocin infusion.

Correct answer: D

Rationale: The correct action for the nurse to take in this scenario is to discontinue the oxytocin infusion. With contractions occurring every 90 seconds with a duration of 90 seconds, the contractions are too frequent and prolonged, which can lead to uterine rupture or fetal distress. Increasing or maintaining the oxytocin infusion would exacerbate the situation, potentially causing harm to the mother and fetus. Decreasing the oxytocin infusion might not be sufficient to address the issue, making discontinuation the most appropriate action to ensure the safety of both the client and the baby.

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