Nursing Elites

1. How should a healthcare professional care for a client approaching death with shortness of breath and noisy respirations?

• A. Turn the client every 2 hours
• B. Provide supplemental oxygen
• C. Use a fan to reduce the feeling of breathlessness
• D. Administer diuretics as prescribed

Correct answer: C

Rationale: In a palliative care setting, when caring for a client approaching death with symptoms of shortness of breath and noisy respirations, using a fan can help alleviate the sensation of breathlessness. This intervention can provide comfort by improving air circulation and reducing the perception of breathlessness. Turning the client every 2 hours may not directly address the respiratory distress caused by noisy respirations. Providing supplemental oxygen may not be indicated or effective in all cases, especially in end-of-life care where the focus is on comfort rather than aggressive interventions. Administering diuretics as prescribed would not be appropriate for addressing noisy respirations and shortness of breath in a dying client, as this may not be related to fluid overload or congestion. Therefore, the most appropriate action to help the client feel more comfortable in this situation is to use a fan to reduce the feeling of breathlessness.

2. A healthcare professional is using the I-SBAR communication tool to provide the client's provider with information about the client. The healthcare professional should convey the client's pain status in which portion of the report?

• A. Assessment
• B. Situation
• C. Background
• D. Recommendation

Correct answer: A

Rationale: In the I-SBAR communication tool, the 'Assessment' portion is where the healthcare professional should convey the client's pain status. This section includes the current patient information, such as the client's pain level, to provide a comprehensive view of the client's condition. Choice B ('Situation') typically involves a brief summary of the client's problem or reason for the communication. Choice C ('Background') usually covers the client's medical history and background information. Choice D ('Recommendation') focuses on the healthcare professional's suggestions or requests regarding the client's care plan, which may include pain management strategies but not the current pain status.

3. When using an open irrigation technique for a client's catheter, what action should the nurse take?

• A. Subtract the amount of irrigant used from the client's urine output.
• B. Add the amount of irrigant used to the urine output measurement.
• C. Measure the amount of irrigant used separately from the urine output.
• D. Document the total amount of fluid used for irrigation only.

Correct answer: A

Rationale: The correct action for the nurse to take when using an open irrigation technique for a client's catheter is to subtract the amount of irrigant used from the client's urine output. This subtraction helps accurately assess the client's output by accounting for the volume of irrigant introduced. Choice B is incorrect because adding the irrigant to the urine output measurement would falsely inflate the total output, leading to inaccurate assessment. Choice C is incorrect as measuring the amount of irrigant separately does not provide an accurate assessment of the client's total output as it disregards the irrigant's contribution. Choice D is incorrect as documenting the total fluid used for irrigation only does not differentiate between the irrigant and the client's actual urine output, which is crucial for accurate monitoring and assessment.

4. What intervention is most important for the LPN/LVN to implement for a male client experiencing urinary retention?

• A. Apply a condom catheter.
• B. Apply a skin protectant.
• C. Encourage increased fluid intake.
• D. Assess for bladder distention.

Correct answer: D

Rationale: The most important intervention for the LPN/LVN to implement for a male client experiencing urinary retention is to assess for bladder distention. This assessment is crucial as it helps identify the underlying cause of urinary retention, such as bladder distention or obstruction. By assessing the bladder, the LPN/LVN can determine the appropriate interventions needed, such as catheterization, medication administration, or further evaluation by the healthcare provider. Applying a condom catheter (Choice A) is more suitable for urinary incontinence, not retention. Applying a skin protectant (Choice B) is typically done to prevent skin breakdown in incontinent clients. Encouraging increased fluid intake (Choice C) may be beneficial for some urinary issues but is not the priority intervention for urinary retention.

5. The nurse is caring for a client with a central venous catheter. What is the most important action for the nurse to take to prevent infection?

• A. Change the catheter dressing every 72 hours.
• B. Flush the catheter with heparin solution daily.
• C. Ensure the catheter is clamped when not in use.
• D. Maintain sterile technique when handling the catheter.

Correct answer: D

Rationale: Maintaining sterile technique when handling a central venous catheter is crucial in preventing infections. Changing the catheter dressing every 72 hours, while important for overall catheter care, does not directly address infection prevention. Flushing the catheter with heparin solution daily is essential for maintaining patency but does not primarily prevent infections. Ensuring the catheter is clamped when not in use is important for preventing air embolism but is not the most critical action to prevent infection. The most effective way to prevent infections is by strictly adhering to sterile techniques during catheter handling, which minimizes the risk of introducing pathogens into the catheter site.

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