Nursing Elites

1. A patient is receiving an opioid analgesic for pain management. What is the most important assessment for the nurse to perform?

• A. Monitor the patient's blood pressure.
• B. Assess the patient's respiratory rate.
• C. Monitor the patient's oxygen saturation.
• D. Assess the patient's heart rate.

Correct answer: B

Rationale: The correct answer is to assess the patient's respiratory rate. When a patient is receiving opioids, it is crucial to monitor their respiratory rate as opioids can depress the respiratory system, leading to respiratory depression and potential respiratory failure. Monitoring blood pressure, oxygen saturation, and heart rate are important assessments as well, but the priority lies in assessing respiratory rate due to the risk of respiratory depression associated with opioid use.

2. A nurse is caring for a patient who has just returned from surgery. What is the nurse's priority action?

• A. Monitor the patient's pain level.
• B. Assess the patient's vital signs.
• C. Assess the surgical incision site.
• D. Position the patient in a high Fowler's position.

Correct answer: B

Rationale: The correct answer is B: Assess the patient's vital signs. Assessing vital signs is crucial as it helps to detect any early signs of complications such as bleeding, shock, or changes in oxygenation. Monitoring the patient's pain level (Choice A) is important but assessing vital signs takes precedence. While assessing the surgical incision site (Choice C) is essential, ensuring the patient's physiological stability through vital sign assessment is the priority. Positioning the patient in a high Fowler's position (Choice D) may be necessary for comfort but does not address the immediate need to assess the patient's condition post-surgery.

3. A nurse is preparing to discontinue a client's indwelling urinary catheter. Which of the following actions should the nurse take first?

• A. Measure and document the urine in the drainage bag
• B. Remove the tape or device securing the catheter to the client's thigh
• C. Position the client supine
• D. Deflate the catheter balloon using a sterile syringe

Correct answer: A

Rationale: The correct first action the nurse should take when discontinuing a client's indwelling urinary catheter is to measure and document the urine in the drainage bag. This step is essential to assess the client's urinary output and bladder function before removing the catheter. Removing the tape securing the catheter (Choice B) or positioning the client supine (Choice C) should come after measuring and documenting the urine output. Deflating the catheter balloon (Choice D) is the last step in the process of removing the catheter.

4. Which intervention reduces reservoirs of infection in a healthcare setting?

• A. Placing capped needles and syringes in puncture-resistant containers
• B. Keeping bedside table surfaces clean and dry
• C. Changing dressings that become wet or soiled
• D. Placing tissues and soiled dressings in paper bags

Correct answer: A

Rationale: Placing capped needles and syringes in puncture-resistant containers is the correct intervention to reduce infection reservoirs in healthcare settings. This practice helps prevent accidental needle-stick injuries and contains potentially infectious materials properly. Keeping bedside table surfaces clean and dry (choice B) is essential for preventing the spread of infections but does not directly address reducing reservoirs of infection. Changing dressings that become wet or soiled (choice C) is important for wound care but does not specifically target infection reservoirs. Placing tissues and soiled dressings in paper bags (choice D) is a proper waste disposal practice but does not directly reduce reservoirs of infection in a healthcare setting.

5. A nurse is preparing an in-service about family violence for a group of newly licensed nurses. Which of the following statements should the nurse include in the teaching?

• A. Perpetrators of family-directed violence do not recognize their behavior as abnormal.
• B. Female clients who experience partner violence are at greater risk for chronic diseases.
• C. The victim's risk for homicide is greatest when they decide to leave the relationship.
• D. The level of violence increases over time in abusive relationships.

Correct answer: C

Rationale: The correct answer is C because the risk of homicide increases significantly when a victim decides to leave an abusive relationship. This is a crucial point to emphasize in educating healthcare professionals about family violence. Choice A is incorrect because perpetrators often do not acknowledge their behavior as abnormal. Choice B is incorrect as victims of partner violence are at greater risk for chronic, not acute, diseases. Choice D is incorrect as the level of violence tends to escalate rather than decrease over time in abusive relationships.

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