Nursing Elites

1. The nurse is caring for an older adult patient with a diagnosis of urinary tract infection (UTI). Upon assessment, the nurse finds the patient confused and agitated. How will the nurse interpret these assessment findings?

• A. These are normal signs of aging.
• B. These are early signs of dementia.
• C. These are purely psychological in origin.
• D. These are common manifestations with UTIs.

Correct answer: D

Rationale: The nurse should interpret confusion and agitation in an older adult patient with a UTI as common manifestations of the infection. In older patients, confusion is a primary symptom of a compromised state due to an acute urinary tract infection or fever. Choice A is incorrect as confusion and agitation are not normal signs of aging. Choice B is incorrect because these symptoms are more likely related to the UTI rather than early signs of dementia. Choice C is incorrect as confusion and agitation in this context are not purely psychological but are likely physiological responses to the UTI.

2. A healthcare provider is preparing to perform mouth care for an unresponsive client. Which of the following actions should the healthcare provider plan to take?

• A. Raise the level of the bed
• B. Administer mouth care with the client in a supine position
• C. Use a tongue depressor to open the mouth
• D. Place the client in a prone position

Correct answer: A

Rationale: Raising the bed level is the correct action to facilitate easier access for mouth care in an unresponsive client. This position enhances the safety and comfort of both the client and the healthcare provider. Administering mouth care with the client in a supine position (lying flat on their back) can increase the risk of aspiration. Using a tongue depressor to open the mouth is not recommended as it can cause discomfort and potential injury. Placing the client in a prone position (lying face down) is contraindicated for mouth care and can compromise the client's airway.

3. A client is incontinent of loose stool and is reporting a painful perineum. Which of the following is the priority nursing action?

• A. Assess the client's perineum
• B. Administer pain medication
• C. Clean the area with a mild cleanser
• D. Apply a barrier cream to the affected area

Correct answer: A

Rationale: Assessing the client's perineum is the priority nursing action in this situation. By checking the perineum, the nurse can evaluate for skin damage, irritation, infection, or other issues that may be causing the client's pain. This assessment is crucial to determine the appropriate interventions needed to address the client's discomfort and prevent complications. Administering pain medication, cleaning the area with a mild cleanser, or applying a barrier cream are important interventions but should follow the initial assessment of the perineum to ensure comprehensive care and effective management of the client's condition. Prioritizing assessment allows for a targeted and individualized approach to care, enhancing the client's overall well-being.

4. When assessing bowel sounds, what action should a healthcare professional take?

• A. Listen to the bowel sounds before performing abdominal palpation
• B. Auscultate for 2 minutes to determine if bowel sounds are present
• C. Place the diaphragm of the stethoscope over each quadrant
• D. Ask the client to cough while auscultating

Correct answer: C

Rationale: When assessing bowel sounds, it is crucial to listen before performing any palpation as palpation can alter bowel sounds. The correct technique involves placing the diaphragm of the stethoscope over each quadrant of the abdomen to listen for bowel sounds. Auscultating for at least 5 minutes is recommended to accurately determine the presence or absence of bowel sounds. Asking the client to cough is not necessary for assessing bowel sounds and may not provide relevant information. Therefore, option C is the correct choice as it follows the appropriate procedure for assessing bowel sounds.

5. A nurse on a medical-surgical unit is receiving a change-of-shift report for four clients. Which of the following clients should the nurse see first?

• A. A client who has new onset of dyspnea 24 hours after a total hip arthroplasty
• B. A client who has acute abdominal pain rated 4 on a scale from 0 to 10
• C. A client who has a UTI and low-grade fever
• D. A client who has pneumonia and an oxygen saturation of 96%

Correct answer: A

Rationale: The nurse should prioritize seeing the client who has new onset dyspnea 24 hours after a total hip arthroplasty first. This sudden dyspnea could indicate a serious complication like a pulmonary embolism, which requires immediate assessment and intervention. Acute abdominal pain, a UTI with a low-grade fever, and pneumonia with an oxygen saturation of 96% are important concerns but are not as immediately life-threatening as potential pulmonary embolism indicated by sudden dyspnea postoperatively.

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