Nursing Elites

1. While administering a cleansing enema, the client reports abdominal cramping. Which of the following actions should the nurse take?

• A. Have the client hold their breath briefly and bear down.
• B. Clamp the enema tubing.
• C. Remind the client that cramping is common at this time.
• D. Raise the level of the enema fluid container.

Correct answer: C

Rationale: When a client reports abdominal cramping during a cleansing enema, it is important for the nurse to reassure the client that cramping is a common side effect. This reassurance helps the client understand that the cramping is normal and may subside once the enema is completed. Instructing the client to hold their breath and bear down (Choice A) is not appropriate and may cause discomfort. Clamping the enema tubing (Choice B) is unnecessary and could lead to complications. Raising the level of the enema fluid container (Choice D) does not address the client's discomfort due to cramping. Therefore, the most suitable action is to provide reassurance to the client about the common occurrence of cramping during the enema.

2. During the initial physical assessment of a newly admitted client with a pressure ulcer, an LPN observes that the client's skin is dry and scaly. The nurse applies emollients and reinforces the dressing on the pressure ulcer. Legally, were the nurse's actions adequate?

• A. The nurse should have also initiated a plan to increase activity.
• B. The nurse provided supportive nursing care for the well-being of the client.
• C. Debridement of the pressure ulcer should have been performed before applying the dressing.
• D. Treatment should not have been initiated until the healthcare provider's prescriptions were received.

Correct answer: B

Rationale: The correct answer is B. Providing supportive nursing care, such as applying emollients and reinforcing the dressing on the pressure ulcer, meets the immediate needs of the client and is in line with legal and professional standards. Option A is incorrect because increasing activity may not be directly related to the immediate skin care needs of the client. Option C is incorrect as debridement might not be immediately necessary based on the initial assessment. Option D is incorrect as nurses are often authorized to initiate treatments within their scope of practice without waiting for healthcare provider prescriptions, especially for routine care like skin moisturization and dressing reinforcement.

3. A charge nurse is observing a newly licensed nurse prepare a sterile field. Which of the following actions should the charge nurse identify as contaminating the sterile field?

• A. The nurse opens the sterile field on a wet surface.
• B. The nurse turns away from the sterile field.
• C. The nurse uses a non-sterile glove to touch the sterile field.
• D. The nurse touches the edge of the sterile drape with her hand.

Correct answer: A

Rationale: The correct answer is A. Opening the sterile field on a wet surface contaminates it, rendering it unsafe for use. Moisture can carry microorganisms that can compromise the sterility of the field. Choice B is incorrect because turning away from the sterile field alone does not necessarily contaminate it unless the nurse touches non-sterile items. Choice C is incorrect because using a non-sterile glove to touch the sterile field directly introduces contaminants. Choice D is incorrect as touching the edge of the sterile drape with a hand may not necessarily contaminate the entire field, unlike opening it on a wet surface.

4. The debilitated patient is resisting attempts by the nurse to provide oral hygiene. Which action will the nurse take next?

• A. Insert an oral airway.
• B. Place the patient in a flat, supine position.
• C. Use undiluted hydrogen peroxide as a cleaner.
• D. Quickly proceed without talking to the patient.

Correct answer: A

Rationale: When a debilitated patient resists oral hygiene, the nurse should prioritize safety. Inserting an oral airway helps keep the mouth open, ensuring adequate access for oral care procedures while preventing any accidental biting or closure of the airway. Placing the patient in a flat, supine position may not address the resistance issue and can lead to aspiration risk. Using undiluted hydrogen peroxide is not recommended due to its potential harmful effects on oral tissues. Proceeding quickly without communication can escalate the situation and compromise patient-centered care.

5. A client with heart failure is being taught by a nurse on reducing daily sodium intake. Which factor is most crucial in determining the client’s ability to learn new dietary habits?

• A. The client's involvement in planning the change
• B. The cost of the dietary changes
• C. The availability of low-sodium foods
• D. The client’s previous dietary knowledge

Correct answer: D

Rationale: The client’s previous dietary knowledge is the most critical factor in determining the ability to learn new dietary habits. Understanding the client's existing dietary knowledge helps tailor the teaching to build upon what they already know. While client involvement in planning changes can increase adherence and motivation, the foundational knowledge is essential for effective learning. The cost of dietary changes and the availability of low-sodium foods are important considerations but not as crucial as the client's existing knowledge.

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