Nursing Elites

1. A nurse is planning preoperative care for a client who will undergo surgery. Which of the following is the priority action by the nurse?

• A. Discuss whether family members will assist with postoperative care
• B. Review the client's current home environment
• C. Identify the client's usual coping mechanisms
• D. Determine what the client knows about the surgery

Correct answer: D

Rationale: In the preoperative phase, determining what the client knows about the surgery is the priority. This action helps address misconceptions, provide necessary information, and ensure the client's understanding and cooperation. Choices A, B, and C are important aspects of preoperative care but assessing the client's knowledge about the surgery takes precedence to alleviate fears, enhance communication, and optimize outcomes.

2. A healthcare professional is preparing to insert an indwelling urinary catheter. What is the most important action to prevent infection?

• A. Use sterile gloves during the procedure.
• B. Clean the catheter insertion site with alcohol.
• C. Insert the catheter as quickly as possible.
• D. Use a smaller catheter size to minimize trauma.

Correct answer: A

Rationale: Using sterile gloves during catheter insertion is crucial to prevent infection. Sterile gloves help maintain asepsis during the procedure, reducing the risk of introducing microorganisms into the urinary tract. Cleaning the insertion site with alcohol, as mentioned in choice B, is important but not as critical as using sterile gloves. Choice C, inserting the catheter as quickly as possible, is not recommended as it can lead to errors and increase the risk of contamination. Choice D, using a smaller catheter size to minimize trauma, is not directly related to preventing infection but rather focuses on patient comfort and reducing tissue damage.

3. When working with a client who does not speak the same language, which of the following actions should the nurse take?

• A. Speak directly to the interpreter
• B. Use family members to translate
• C. Speak directly to the patient
• D. Use medical jargon

Correct answer: C

Rationale: When caring for a client who does not speak the same language, it is essential for the nurse to speak directly to the patient. This approach helps maintain rapport, establishes a trusting relationship, and ensures better communication. Speaking to the interpreter instead of the patient can lead to misunderstandings and hinder the therapeutic relationship. Using family members to translate is not recommended as they may not provide accurate or confidential information. Lastly, using medical jargon can further complicate communication and may not be understood by the patient.

4. What are the key components of a pain assessment in a postoperative patient?

• A. Checking the effectiveness of pain interventions
• B. Observing for nonverbal signs of pain like grimacing
• C. Assessing the location, duration, and quality of the pain
• D. Asking the patient to rate their pain on a scale of 1-10

Correct answer: A

Rationale: The correct answer is A because in a postoperative patient, it is crucial to evaluate the effectiveness of the pain interventions that have been implemented. While choices B, C, and D are important aspects of a pain assessment, they do not specifically address the key component of assessing the effectiveness of the interventions applied postoperatively.

5. Which goal is most appropriate for a patient who has had a total hip replacement?

• A. The nurse will assist the patient in ambulating in the hall 2 times a day.
• B. The patient will walk 100 feet using a walker by the time of discharge.
• C. The patient will ambulate briskly on the treadmill by the time of discharge.
• D. The patient will ambulate independently by the time of discharge.

Correct answer: B

Rationale: Choice B is the most appropriate goal for a patient who has had a total hip replacement because it is specific, measurable, and achievable. Walking 100 feet using a walker is a realistic and individualized target for a patient in the recovery phase following hip surgery. Choices A, C, and D are not as suitable: Choice A does not specify a measurable distance or objective, Choice C sets a potentially unrealistic expectation for brisk ambulation on a treadmill, and Choice D lacks the specificity of the distance to be walked.

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