Nursing Elites

1. A client is preparing to administer an enema to a 64-year-old client. Which of the following actions of the nurse is most appropriate?

• A. Assist the client to lie in the semi-Fowler position
• B. Apply lubricating jelly to the tip of the catheter before insertion
• C. Instill a total of 30cc of fluid into the client's rectum
• D. Ask the client to hold the solution in for 30 seconds

Correct answer: B

Rationale: When administering an enema to a client, the nurse should place the client in the Sims' position for easy access. The correct action is to apply lubricating jelly to the tip of the catheter before insertion to facilitate a smoother procedure. It is essential to instill a maximum of 750 to 1000 cc of fluid for an adult client, not just 30cc. Following administration, the nurse should ask the client to hold the solution for at least 5 minutes to allow for the desired effect of the enema. Therefore, choice B is the most appropriate action, as choices A, C, and D are incorrect due to inaccuracies in positioning, enema volume, and retention time.

2. Which practice will help reduce the risk of a needlestick injury?

• A. Expose the end of the needle only when ready to enter the room for the procedure
• B. Never recap a needle after use
• C. Keep a sharps container nearby where it can be easily accessed
• D. Exchange needles from a central area rather than passing them between workers

Correct answer: C

Rationale: To reduce the risk of a needlestick injury, it is essential to keep a sharps container nearby where it can be easily accessed. This practice ensures quick and safe disposal of needles after use, minimizing the chances of accidental needlesticks. Recapping needles should be avoided as it increases the risk of injuries. Passing needles between workers should also be avoided to prevent accidental needle pricks during handovers. Therefore, the best practice to prevent needlestick injuries is to maintain a sharps container nearby for safe and immediate disposal of needles.

3. The nurse is developing a plan of care for an infant after surgical intervention for imperforate anus. The nurse should include in the plan that which position is the most appropriate one for the infant in the postoperative period?

• A. Prone position
• B. Supine with no head elevation
• C. Side-lying with the legs extended
• D. Supine with the head elevated 45 degrees

Correct answer: A

Rationale: The most appropriate position for an infant after surgical intervention for imperforate anus is the prone position. Placing the infant in a prone position helps keep the hips elevated, reducing edema and pressure on the surgical site. This position promotes optimal healing and comfort for the infant. Option B, supine with no head elevation, does not provide the necessary elevation to reduce pressure on the surgical site. Option C, side-lying with the legs extended, does not offer the same benefits as the prone position in terms of reducing pressure on the surgical site. Option D, supine with the head elevated 45 degrees, does not specifically address the need for hip elevation to prevent pressure on the surgical site. Therefore, the correct choice is the prone position for this postoperative care scenario.

4. When planning a cultural assessment, what component should the nurse include?

• A. Family history
• B. Chief complaint
• C. Medical history
• D. Health practices

Correct answer: D

Rationale: When conducting a cultural assessment, it is essential to include the patient's health practices. Health practices encompass the beliefs, values, and behaviors related to health and illness within a specific cultural context. These practices provide insight into how individuals perceive and manage their health. Family history, chief complaint, and medical history are crucial components of a patient's overall assessment but do not directly relate to a cultural assessment. Focusing on health practices allows the nurse to better understand the patient's cultural background and tailor care to meet their specific needs.

5. A client is being assisted to lie in the Sims' position. In what position does the nurse arrange the client?

• A. The client lies on his side with the upper leg flexed
• B. The client lies on his back with his head lower than his feet
• C. The client lies on his abdomen with a pillow supporting his head
• D. The client is sitting up at a 90-degree angle

Correct answer: A

Rationale: The Sims' position is a side-lying position used for examinations or comfort. In the Sims' position, the client lies on their side with the upper leg flexed. The abdomen is slightly downward, and the lower arm is positioned behind the body. A pillow can be used to support the leg. Choice B is incorrect as it describes a position with the client lying on their back with the head lower than the feet. Choice C is incorrect as it describes a prone position, not the Sims' position. Choice D is incorrect as it describes a sitting position, not the Sims' position.

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