Nursing Elites

1. Which of the following principles of primary nursing has proven the most satisfying to the patient and nurse?

• A. Administer oxygen by Venturi mask at 24% as needed
• B. Allow a 1-hour rest period between activities
• C. Patients and nurses both respond well to primary nursing care units
• D. Studies have shown that patients and nurses both respond well to primary nursing care units

Correct answer: C

Rationale: Primary nursing care units have been proven to be highly satisfying for both patients and nurses. This model promotes a consistent and continuous relationship between a patient and a primary nurse, leading to improved communication, personalized care, and overall satisfaction for both parties involved.

2. What is the term for the body's ability to defend itself against specific invading agents such as bacteria, toxins, viruses, and foreign bodies?

• A. Hormones
• B. Secretion
• C. Immunity
• D. Glands

Correct answer: C

Rationale: The correct answer is C: Immunity. Immunity refers to the body's ability to protect itself against specific invading agents like bacteria, toxins, viruses, and foreign bodies by recognizing and destroying them. It is a crucial defense mechanism that helps maintain health and prevent infections and diseases. Choices A, B, and D are incorrect because hormones are chemical messengers, secretion is the process of releasing substances, and glands are organs that produce and release substances, none of which specifically relate to the body's defense against invading agents.

3. A client with heart failure has a new prescription for furosemide. Which of the following statements should the nurse make?

• A. Taking furosemide can cause your potassium levels to be high
• B. Eat foods that are high in sodium
• C. Rise slowly when getting out of bed
• D. Taking furosemide can cause you to be overhydrated

Correct answer: C

Rationale: Educating the client on the importance of rising slowly when getting out of bed is crucial due to the risk of orthostatic hypotension associated with furosemide use. This precaution helps prevent dizziness and falls. Options A and D are incorrect as furosemide commonly causes hypokalemia and dehydration, respectively, rather than high potassium levels or overhydration. Option B is inaccurate as clients on furosemide need to reduce sodium intake to manage fluid retention.

4. A male patient who had surgery 2 days ago for head and neck cancer is about to make his first attempt to ambulate outside his room. The nurse notes that he is steady on his feet and that his vision was unaffected by the surgery. Which of the following nursing interventions would be appropriate?

• A. Encourage the patient to walk in the hall alone
• B. Discourage the patient from walking in the hall for a few more days
• C. Accompany the patient for his walk
• D. Consult a physical therapist before allowing the patient to ambulate

Correct answer: C

Rationale: Accompanying the patient for his walk is the appropriate nursing intervention in this scenario to ensure his safety during his first ambulation. This allows the nurse to provide immediate assistance if needed and ensures the patient's well-being during this critical postoperative period.

5. A client who is at 38 weeks gestation, is in active labor, and has ruptured membranes is being cared for by a nurse. What action should the nurse take?

• A. Insert an indwelling urinary catheter
• B. Apply fetal heart rate monitor
• C. Initiate fundal massage
• D. Initiate an oxytocin IV infusion

Correct answer: B

Rationale: When caring for a client in active labor with ruptured membranes, the priority action for the nurse is to apply a fetal heart rate monitor. This helps monitor the well-being of the fetus during labor and delivery, enabling timely interventions if any fetal distress is detected. Inserting an indwelling urinary catheter may be required in some cases, but it is not the priority in the given scenario. Fundal massage is typically done after delivery to help the uterus contract and prevent postpartum hemorrhage. Initiating an oxytocin IV infusion may be indicated to augment labor, but it is not the initial action needed in this situation.

Similar Questions