Nursing Elites

1. An older client who had abdominal surgery 3 days earlier was given a barbiturate for sleep and is now requesting to go to the bathroom. Which action should the nurse implement?

• A. Assist the client to walk to the bathroom and do not leave the client alone.
• B. Request that the UAP assist the client onto a bedpan.
• C. Ask if the client needs to have a bowel movement or void.
• D. Assess the client's bladder to determine if the client needs to urinate.

Correct answer: A

Rationale: Barbiturates cause central nervous system (CNS) depression, increasing the risk of falls. It is crucial for the nurse to assist the client to the bathroom to prevent potential injuries. Leaving the client alone may lead to accidents due to the effects of the medication. Monitoring and supporting the client during this activity is essential for ensuring safety and preventing falls.

2. By rolling contaminated gloves inside-out, the healthcare professional is affecting which step in the chain of infection?

• A. Mode of transmission
• B. Portal of entry
• C. Reservoir
• D. Portal of exit

Correct answer: A

Rationale: When contaminated gloves are rolled inside-out, they are serving as a mode of transmission by carrying pathogens from the reservoir's portal of exit to a new portal of entry. This action increases the risk of transmitting infections from one person to another, emphasizing the importance of proper glove removal techniques to prevent the spread of pathogens. Choices B, C, and D are incorrect in this context. Portal of entry refers to the route through which a pathogen enters a susceptible host, reservoir is the habitat where the pathogen lives, grows, and multiplies, and portal of exit is the path through which a pathogen leaves its host.

3. The client has received a new diagnosis of heart failure, and the nurse is providing dietary management education. Which instruction should the nurse include?

• A. Increase intake of foods high in potassium.
• B. Avoid foods high in sodium.
• C. Limit fluid intake to 1.5 liters per day.
• D. Increase intake of foods high in vitamin K.

Correct answer: B

Rationale: Avoiding foods high in sodium (choice B) is essential for clients with heart failure to prevent fluid retention and decrease the strain on the heart. High sodium intake can lead to fluid buildup, exacerbating heart failure symptoms. Increasing potassium intake (choice A) can be harmful in heart failure if not monitored closely as it can affect heart rhythm. Limiting fluid intake (choice C) may be necessary in some cases, but the specific amount should be individualized based on the client's condition. Increasing vitamin K intake (choice D) is not a primary concern in heart failure management and is more relevant for clients on anticoagulants to manage blood clotting.

4. What type of technique should the nurse observe when preparing to insert an indwelling catheter?

• A. Clean technique.
• B. Medical Asepsis.
• C. Isolation Protocol.
• D. Sterile Technique.

Correct answer: D

Rationale: When inserting an indwelling catheter, the nurse must observe sterile technique to minimize the risk of infections. Sterile technique involves using sterile equipment and maintaining a sterile field to prevent introducing pathogens into the urinary tract.

5. The healthcare provider plans to administer diazepam, 4 mg IV push, to a client with severe anxiety. How many milliliters should the healthcare provider administer? (Round to the nearest tenth.)

• A. 0.2 mL
• B. 0.8 mL
• C. 1.25 mL
• D. 2.0 mL

Correct answer: B

Rationale: To calculate the volume to administer, use the formula (1 mL × 4 mg) / 5 mg = 0.8 mL. The healthcare provider should administer 0.8 mL of diazepam for a dosage of 4 mg IV push. Choice A is incorrect because it results from an incorrect calculation. Choices C and D are incorrect as they do not align with the correct calculation based on the provided dosage.

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