Nursing Elites

1. 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.

2. A client who is in hospice care complains of increasing amounts of pain. The healthcare provider prescribes an analgesic every four hours as needed. Which action should the nurse implement?

• A. Give analgesics on an around-the-clock schedule for pain management.
• B. Administer analgesic medication only when the pain becomes severe.
• C. Provide medication to keep the client comfortable without inducing sedation.
• D. Allow brief medication-free periods to promote comfort during daily activities.

Correct answer: A

Rationale: The most effective pain management strategy in hospice care involves administering analgesics on an around-the-clock schedule (A) to maintain pain control. Waiting until pain is severe before administering medication (B) is not ideal as it may lead to inadequate pain relief. While providing comfort is crucial in hospice care, sedation that prevents the client from interacting and experiencing their remaining time should be minimized. Therefore, keeping the client comfortable without excessive sedation (C) is preferred. Allowing for some periods without medication (D) may be appropriate but should not compromise the client's comfort and pain control.

3. Earlier this morning, an elderly Hispanic female was discharged to a LTC facility. The family members are now gathered in the hallway outside her room. What is the best action?

• A. Ask the family to wait in the cafeteria while the next of kin makes the necessary arrangements
• B. Provide space and privacy for the family to share their concerns about the client’s discharge
• C. Ask the social worker to encourage the family to clear the hallway
• D. Explain to the family the client’s need for privacy so that she can make independent decisions

Correct answer: B

Rationale: In this situation, providing space and privacy for the family allows them to openly discuss their concerns regarding the client’s discharge. It respects the family's need for support, communication, and involvement in the decision-making process, ultimately fostering a more effective and compassionate care environment.

4. When a male client mentions his foot is hurting while watching TV with his wife, how should the nurse respond?

• A. Ask him to rate his pain on a scale of 1 to 10.
• B. Encourage him to wait until bedtime for the pill to help him sleep.
• C. Attend to an acutely ill client's needs first as the client is laughing.
• D. Instruct him in the use of deep breathing exercises for pain control.

Correct answer: A

Rationale: The correct response is to ask the client to rate his pain on a scale of 1 to 10. This helps the nurse assess the intensity of the pain and determine the appropriate pain medication. Encouraging him to wait or attend to another client's needs first are incorrect because pain management should be addressed promptly. Instructing on deep breathing exercises may be helpful but is not the initial step in addressing acute pain.

5. A client is admitted with a diagnosis of heart failure. Which dietary instruction should the nurse provide?

• A. Increase fluid intake to 3 liters per day.
• B. Limit sodium intake to 2 grams per day.
• C. Avoid foods high in potassium.
• D. Increase protein intake to promote healing.

Correct answer: B

Rationale: Limiting sodium intake to 2 grams per day (B) is a crucial dietary instruction for clients with heart failure. It helps manage fluid retention and reduces the workload on the heart. Excessive sodium can lead to fluid retention, worsening heart failure symptoms. Increasing fluid intake (A) can further exacerbate fluid overload in heart failure patients. Avoiding foods high in potassium (C) is not necessary unless the client has hyperkalemia; in heart failure, potassium restriction is not a primary dietary concern. Increasing protein intake (D) is not the priority for heart failure management; focusing on sodium restriction is more beneficial.

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