Nursing Elites

1. A nurse is preparing to perform postmortem care for a client. Which of the following actions should the nurse take?

• A. Place the client's dentures in a labeled container
• B. Remove the client's IV lines
• C. Place the client's body in a semi-fowler's position
• D. Lower the client's head of the bed

Correct answer: B

Rationale: The correct action for the nurse to take when preparing to perform postmortem care is to remove the client's IV lines. This step is essential to help maintain the dignity and appearance of the body. Placing the client's dentures in a labeled container (Choice A) is not a priority during postmortem care as the focus is on the body's preparation. While positioning the body in a semi-fowler's position (Choice C) or lowering the client's head of the bed (Choice D) are common practices for living clients to prevent aspiration, they are not necessary after death. Therefore, the immediate action of removing IV lines is most appropriate in this situation.

2. A nurse is caring for a client who has an indwelling urinary catheter. Which of the following interventions should the nurse implement to prevent catheter-associated infections?

• A. Change the catheter every 24 hours
• B. Ensure the drainage bag is positioned above the bladder
• C. Perform routine irrigation of the catheter
• D. Empty the drainage bag every 4 hours

Correct answer: B

Rationale: The correct answer is to ensure the drainage bag is positioned above the bladder. This positioning prevents urine reflux into the bladder, reducing the risk of catheter-associated infections. Changing the catheter too frequently (Choice A) can actually increase the risk of infection by introducing pathogens. Performing routine catheter irrigation (Choice C) is no longer recommended as it can increase the risk of infection by introducing bacteria. Emptying the drainage bag every 4 hours (Choice D) is a standard practice to prevent urinary stasis but is not directly related to preventing catheter-associated infections.

3. A nurse in a mental health facility is caring for a client who is angry and throwing objects at staff members. Which of the following actions should the nurse take?

• A. Ask the client to identify what made them angry.
• B. Instruct the client to calm down.
• C. Place the client in seclusion.
• D. Encourage the client to attend group therapy.

Correct answer: C

Rationale: During a situation where a client is exhibiting violent behavior like throwing objects and posing a risk to themselves and others, the immediate priority is to ensure the safety of all involved. Placing the client in seclusion is a necessary intervention to prevent harm and allow for de-escalation. Asking the client to identify the trigger or instructing them to calm down may not be effective or safe in this escalated state. Encouraging the client to attend group therapy is not suitable when they are in an agitated and aggressive state that requires immediate intervention.

4. A healthcare professional is reviewing the laboratory values of a client who has cirrhosis. Which of the following findings should the healthcare professional report to the provider?

• A. Ammonia 75 mcg/dL
• B. Sodium 142 mEq/L
• C. Calcium 9.5 mg/dL
• D. Bilirubin 2.5 mg/dL

Correct answer: D

Rationale: An elevated bilirubin level in clients with cirrhosis indicates worsening liver function and potential complications. It is crucial to report this finding promptly as it may require immediate medical intervention. Elevated ammonia levels (choice A) are also concerning in cirrhosis, indicating hepatic encephalopathy, but bilirubin levels are more specific to liver function in this context. Choices B and C are within normal ranges and are not typically of immediate concern in cirrhosis.

5. A nurse is providing teaching to a client who has a new prescription for an albuterol inhaler. Which of the following instructions should the nurse include?

• A. Take one puff every 5 minutes until symptoms improve.
• B. Hold your breath for 10 seconds after inhaling the medication.
• C. Shake the inhaler for 2 seconds before use.
• D. Exhale forcefully after each puff.

Correct answer: B

Rationale: The correct answer is B. Instructing the client to hold their breath for 10 seconds after inhaling the medication allows it to reach deeper into the lungs for maximum effectiveness. Choice A is incorrect because taking one puff every 5 minutes may lead to overuse of the medication. Choice C is incorrect as shaking the inhaler for only 2 seconds may not provide adequate mixing of the medication. Choice D is incorrect because exhaling forcefully after each puff may reduce the amount of medication that reaches the lungs.

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