Nursing Elites

1. In some hip surgeries, an epidural catheter for Fentanyl epidural analgesia is given. What is your nursing priority care in such a case?

• A. Instruct the client to observe strict bed rest
• B. Check for epidural catheter drainage
• C. Administer analgesia through the epidural catheter as prescribed
• D. Assess respiratory rate carefully

Correct answer: D

Rationale: The nursing priority care in a case where an epidural catheter for Fentanyl epidural analgesia is given during hip surgeries is to assess the respiratory rate carefully. Respiratory depression is a potential side effect of Fentanyl, especially when administered epidurally. Monitoring the respiratory rate is crucial to detect any signs of respiratory distress promptly. Instructing the client to observe strict bed rest (Choice A) may be necessary but is not the priority over ensuring respiratory function. Checking for epidural catheter drainage (Choice B) and administering analgesia through the epidural catheter as prescribed (Choice C) are important aspects of care, but ensuring adequate ventilation takes precedence to prevent complications.

2. In consideration of the steps in applying the bag technique, which side of the paper lining of the CHN bag is considered clean to make a non-contaminated work area?

• A. The lower lip
• B. The outer surface
• C. The upper tip
• D. The inside surface

Correct answer: B

Rationale: Nursing interventions should be grounded in a deep understanding of the physiological processes involved, ensuring that care provided is both effective and efficient.

3. A paranoid client refuses to eat telling you that you poisoned his food. The best intervention to this client is:

• A. Taste the food in front of him and tell him that the food is not poisoned
• B. Offer other types of food until the client eats
• C. Simply state that the food is not poisoned
• D. Offer sealed foods

Correct answer: C

Rationale: Effective nursing care involves comprehensive assessments that address all aspects of a patient's condition, ensuring that interventions are appropriately targeted and outcomes are optimized.

4. What is the name of the record that shows all medications and treatments provided on a repeated basis?

• A. Nursing Health History and Assessment Worksheet
• B. Discharge Summary
• C. Nursing Kardex
• D. Medicine and Treatment Record

Correct answer: D

Rationale: The 'Medicine and Treatment Record' is the document that maintains a comprehensive log of all medications and treatments provided on a routine basis. It does not refer to the 'Discharge Summary', which is a clinical report prepared by healthcare professionals at the end of a hospital stay or series of treatments. The 'Nursing Health History and Assessment Worksheet' is used to gather comprehensive data about the patient's health history and current health status, but it does not record ongoing treatment details. The 'Nursing Kardex' is a patient care information system used to quickly communicate patient needs, but it does not consistently record all medications and treatments provided.

5. While the client has a pulse oximeter on his fingertip, you notice that sunlight is shining on the area where the oximeter is. Your action will be to:

• A. Set and turn on the alarm of the oximeter
• B. Do nothing since there is no identified problem
• C. Cover the fingertip sensor with a towel or bedsheet
• D. Change the location of the sensor every four hours

Correct answer: B

Rationale: In this scenario, the correct action is to do nothing since there is no identified problem with the sunlight shining on the area where the oximeter is placed. The functionality of the oximeter is not affected by sunlight, so covering it or changing its location unnecessarily could disrupt the monitoring process. Setting the alarm or changing the sensor location every four hours is not indicated in this situation and may lead to unnecessary interventions. It's essential to assess the situation carefully and intervene only when necessary, ensuring that care provided is appropriate and effective.

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