Nursing Elites

1. When emptying 350 mL of pale yellow urine from a client's urinal, the nurse notes that this is the first time the client has voided in 4 hours. Which action should the nurse take next?

• A. Record the amount on the client's fluid output record.
• B. Encourage the client to increase oral fluid intake.
• C. Notify the healthcare provider of the findings.
• D. Palpate the client's bladder for distention.

Correct answer: A

Rationale: The nurse should record the amount on the client's fluid output record because the 350 mL of pale yellow urine is a normal finding. This indicates appropriate urine output, so encouraging increased fluid intake or notifying the healthcare provider is not necessary at this time. Additionally, palpating the client's bladder for distention is not indicated based on the normal urine output observed.

2. How should the nurse prepare the body of a deceased adult for transfer to the mortuary?

• A. Leave the body as is, no preparation needed
• B. Bathe the body and place ID tags on it
• C. Remove dentures before bathing the body
• D. Position the body with its head down and arms folded on its chest

Correct answer: B

Rationale: When preparing the body of a deceased adult for transfer to the mortuary, it is essential to bathe the body and place identification tags on it. This process ensures proper identification and respectful care of the deceased individual.

3. While observing an unlicensed assistive personnel (UAP) providing a total bed bath for a confused and lethargic client, the nurse notes the UAP soaking the client’s foot in a basin of warm water placed on the bed. What action should the nurse take?

• A. Remove the basin of water from the client’s bed immediately
• B. Remind the UAP to dry between the client’s toes completely
• C. Advise the UAP that this procedure may lead to skin damage
• D. Add skin cream to the basin of water while the foot is soaking

Correct answer: B

Rationale: The correct action for the nurse to take in this situation is to remind the unlicensed assistive personnel (UAP) to dry between the client’s toes completely. Failing to dry between the toes can lead to skin breakdown due to excessive moisture accumulation. Proper drying is essential to maintain skin integrity and prevent complications in the client's care. Removing the basin of water immediately may disrupt the care process and not address the root cause of the issue. Advising about potential skin damage is not as direct and actionable as reminding to dry between the toes. Adding skin cream to the water may not be appropriate without specific orders and can potentially worsen the situation by increasing moisture.

4. A healthcare professional stops at a motor vehicle collision site to render aid until the emergency personnel arrive and applies pressure to a groin wound that is bleeding profusely. Later, the client has to have the leg amputated and sues the healthcare professional for malpractice. What is the most likely outcome of this lawsuit?

• A. The Patient's Bill of Rights protects clients from malicious intents, so the healthcare professional could lose the case.
• B. The lawsuit may be settled out of court, but the healthcare professional's license is likely to be revoked.
• C. There will be no judgment against the healthcare professional, whose actions were protected under the Good Samaritan Act.
• D. The client will win because the four elements of negligence (duty, breach, causation, and damages) can be proved.

Correct answer: C

Rationale: The Good Samaritan Act protects healthcare professionals who provide care in good faith and offer reasonable assistance in emergencies. This law shields them from malpractice claims, even if the outcome for the client is unfavorable. In this scenario, the healthcare professional is likely to be protected from judgment under the Good Samaritan Act. Choice A is incorrect because the situation does not involve the Patient's Bill of Rights, but rather the Good Samaritan Act. Choice B is incorrect as the license revocation is not a typical outcome in Good Samaritan cases. Choice D is incorrect as the Good Samaritan Act provides immunity from liability in such emergency situations.

5. When assessing a client with a nursing diagnosis of fluid volume deficit, the nurse notes that the client's skin over the sternum 'tents' when gently pinched. Which action should the nurse implement?

• A. Confirm the finding by further assessing the client for jugular vein distention.
• B. Offer the client high-protein snacks between regularly scheduled mealtimes.
• C. Continue the planned nursing interventions to restore the client's fluid volume.
• D. Change the plan of care to include interventions for impaired skin integrity.

Correct answer: C

Rationale: When the nurse observes that the client's skin over the sternum 'tents' when gently pinched, it is a classic sign of fluid volume deficit. This finding indicates dehydration and the need to restore the client's fluid volume. Therefore, the appropriate action for the nurse is to continue the planned nursing interventions aimed at addressing the fluid deficit. Choice A is incorrect as jugular vein distention is associated with fluid overload, not deficit. Choice B is incorrect as offering high-protein snacks does not directly address the fluid volume deficit. Choice D is incorrect as the priority is to address the fluid deficit before addressing skin integrity issues.

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