Nursing Elites

1. When caring for a client with a urinary catheter, what is the most important intervention to prevent infection?

• A. Use sterile technique for catheter care
• B. Ensure the catheter bag is below the level of the bladder
• C. Provide perineal care daily
• D. Change the catheter only when necessary

Correct answer: B

Rationale: The most important intervention to prevent infection when caring for a client with a urinary catheter is to ensure that the catheter bag is below the level of the bladder. This positioning helps prevent urine backflow, reducing the risk of infection. While using sterile technique for catheter care (Choice A) is important, ensuring proper drainage by keeping the catheter bag below the bladder is crucial to prevent infection. Providing perineal care daily (Choice C) is essential for hygiene but not directly related to preventing catheter-related infections. Changing the catheter only when necessary (Choice D) is important for maintenance, but correct positioning of the catheter bag is more critical in preventing immediate infection.

2. A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with shortness of breath. What is the priority nursing intervention?

• A. Administer a high-flow oxygen mask.
• B. Position the client in a high-Fowler's position.
• C. Provide a high-carbohydrate diet.
• D. Encourage the client to cough and deep breathe.

Correct answer: B

Rationale: The priority nursing intervention for a client with COPD experiencing shortness of breath is to position the client in a high-Fowler's position. This position helps improve lung expansion and breathing by reducing respiratory effort. Administering a high-flow oxygen mask (Choice A) may be necessary but is not the priority intervention. Providing a high-carbohydrate diet (Choice C) is not directly related to managing acute shortness of breath in COPD. Encouraging the client to cough and deep breathe (Choice D) is helpful for airway clearance but is not the priority intervention when the client is in distress with acute shortness of breath.

3. A client with pneumonia is experiencing difficulty expectorating thick secretions. What intervention should the nurse implement to assist the client?

• A. Administer antibiotics as prescribed
• B. Perform chest physiotherapy
• C. Encourage increased fluid intake
• D. Provide humidified oxygen

Correct answer: C

Rationale: The correct intervention for a client experiencing difficulty expectorating thick secretions due to pneumonia is to encourage increased fluid intake. Increasing fluid intake helps to thin secretions, making them easier to expectorate. Administering antibiotics (Choice A) is important in treating pneumonia but does not directly address the issue of thick secretions. Chest physiotherapy (Choice B) may help in some cases, but increasing fluid intake is a more straightforward and effective intervention. Providing humidified oxygen (Choice D) can help with oxygenation but does not directly address the problem of thick secretions.

4. Based on the Nursing diagnosis of 'Potential for infection related to second and third degree burns,' which intervention has the highest priority?

• A. Application of topical antibacterial cream
• B. Use of careful hand washing technique
• C. Administration of plasma expanders
• D. Limiting visitors to the burned client

Correct answer: B

Rationale: The highest priority intervention in this scenario is B, the use of careful hand washing technique. Proper hand hygiene is essential in preventing infection, especially in individuals with compromised skin integrity like those with burns. By practicing careful hand washing, healthcare providers reduce the risk of introducing harmful pathogens to the burn wound, thus lowering the chances of infections. Choice A, application of topical antibacterial cream, is important but should follow ensuring proper hand hygiene. Choice C, administration of plasma expanders, is not directly associated with preventing burn-related infections. Choice D, limiting visitors, is significant for infection control, but ensuring proper hand hygiene outweighs this intervention in terms of priority.

5. What action should the nurse implement in caring for a client following an electroencephalogram (EEG)?

• A. Monitor the client's vital signs every 4 hours
• B. Assess the client's lower extremities for sensation
• C. Instruct the client to maintain bed rest
• D. Wash any paste from the client's hair and scalp

Correct answer: D

Rationale: The correct action the nurse should implement after an EEG is to wash any paste from the client's hair and scalp. This is crucial to prevent irritation and infection at the EEG site. Monitoring vital signs every 4 hours is not specifically indicated after an EEG. Assessing the client's lower extremities for sensation is unrelated to caring for a client post-EEG. While rest may be recommended after the procedure, there is no standard requirement for a specific duration of bed rest.

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