Nursing Elites

1. An angry client screams at the emergency department triage nurse, 'I've been waiting here for two hours! You and the staff are incompetent.' What is the best response for the nurse to make?

• A. The emergency department is very busy at this time.
• B. I'll let you see the doctor next because you've waited so long.
• C. I'm doing the best I can for the sickest clients first.
• D. I understand you are frustrated with the wait time.

Correct answer: D

Rationale: The correct response for the nurse is to choose option D, 'I understand you are frustrated with the wait time.' This response acknowledges the client's emotions, shows empathy, and validates their feelings of frustration. Option A justifies the situation but does not address the client's emotional state. Option B is unfair to other patients and may not be based on urgency. Option C focuses on the nurse's actions rather than addressing the client's emotions, making it less effective than option D.

2. The nurse-manager of a perinatal unit is notified that one client from the medical-surgical unit needs to be transferred to make room for new admissions. Which client should the nurse recommend for transfer to the antepartal unit?

• A. A 45-year-old with chronic hepatitis B.
• B. A 35-year-old with lupus erythematosus
• C. A 19-year-old diagnosed with rubella
• D. A 25-year-old with herpes lesions of the vulva

Correct answer: B

Rationale: The correct answer is B because a client with lupus erythematosus can be safely transferred to the antepartal unit as this condition does not pose a significant risk to other patients or staff. Choices A, C, and D should not be recommended for transfer to the antepartal unit due to the potential risks they may pose to pregnant women and their unborn babies. Chronic hepatitis B, rubella, and herpes lesions of the vulva can be contagious and harmful in the perinatal setting.

3. Which assessment finding is most indicative of deep vein thrombosis (DVT) in a client's right leg?

• A. Dorsiflexes the right foot and left on command
• B. A 3 by 5 cm ecchymosis area covering the right calf
• C. Right calf is 3 cm larger in circumference than the left
• D. Bilateral lower extremity has 3+ pitting edema

Correct answer: C

Rationale: The correct answer is C because a significant increase in the circumference of the right calf compared to the left calf is a classic sign of deep vein thrombosis (DVT). Option A is incorrect as dorsiflexing the right foot and left on command does not specifically indicate DVT. Option B describes an ecchymosis area which is more indicative of a bruise rather than DVT. Option D suggests bilateral lower extremity edema, which is not specific to DVT and can be seen in various conditions such as heart failure or renal issues.

4. A client who had a cerebral vascular accident (CVA) is paralyzed on the left side of the body and has developed a Stage II pressure ulcer on the left hip. Which nursing diagnosis describes this client's current health status?

• A. Risk for impaired tissue integrity related to impaired physical mobility
• B. Impaired skin integrity related to altered circulation and pressure
• C. Ineffective tissue perfusion related to inability to move self in bed
• D. Impaired physical mobility related to the left side paralysis

Correct answer: B

Rationale: The correct nursing diagnosis for this client is 'Impaired skin integrity related to altered circulation and pressure.' The client's Stage II pressure ulcer on the left hip is a clear indication of impaired skin integrity resulting from altered circulation and pressure due to immobility. Choice A is incorrect because the client already has a pressure ulcer, indicating an actual impairment rather than a risk. Choice C is incorrect as ineffective tissue perfusion is not the primary issue in this case. Choice D is incorrect as it focuses solely on the paralysis and not the actual skin integrity issue.

5. A nurse is preparing to insert an indwelling urinary catheter in a female client. Which action should the nurse take to maintain sterile technique?

• A. Apply sterile gloves before inserting the catheter
• B. Use sterile gloves to insert the catheter
• C. Clean the urinary meatus with an antiseptic solution
• D. Place the drainage bag above the level of the bladder

Correct answer: B

Rationale: Using sterile gloves to insert the catheter is crucial to maintaining sterile technique. Sterile gloves help prevent the introduction of microorganisms during the insertion process. Applying sterile gloves before cleansing the perineal area (Choice A) is important but not specific to maintaining sterility during catheter insertion. Cleaning the urinary meatus with an antiseptic solution (Choice C) is a step in the catheterization process but does not solely ensure sterile technique. Placing the drainage bag above the level of the bladder (Choice D) is incorrect; the bag should be placed below the level of the bladder to facilitate urine drainage.

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