Nursing Elites

1. A client is experiencing difficulty voiding following the removal of an indwelling catheter. What action should the nurse take to assist the client?

• A. Assess for bladder distention after 4 hours
• B. Pour warm water over the perineum
• C. Restrict the client's oral fluid intake
• D. Restrict movement for at least 12 hours

Correct answer: B

Rationale: The correct action for the nurse to assist the client who is experiencing difficulty voiding after the removal of an indwelling catheter is to pour warm water over the perineum. This technique can help stimulate urination by promoting relaxation of the perineal muscles and improving blood flow to the area. Assessing for bladder distention after 4 hours (Choice A) is important but not the immediate intervention needed to assist the client in voiding. Restricting the client's oral fluid intake (Choice C) can exacerbate the issue by reducing urine production. Restricting movement for at least 12 hours (Choice D) is unnecessary and may lead to discomfort and other complications.

2. What are the nursing interventions for a patient experiencing hypoglycemia?

• A. Administer glucose or dextrose and monitor blood sugar levels
• B. Monitor vital signs and provide a high-carbohydrate snack
• C. Monitor for sweating and confusion
• D. Provide insulin and assess for hyperglycemia

Correct answer: A

Rationale: The correct answer is A. Administering glucose or dextrose is a crucial nursing intervention for a patient experiencing hypoglycemia as it helps to quickly raise blood sugar levels. Monitoring blood sugar levels is essential to ensure that the patient's glucose levels normalize. Choice B is incorrect because providing a high-carbohydrate snack may not be sufficient to rapidly raise blood sugar levels in severe hypoglycemia. Choice C is incorrect because while monitoring for sweating and confusion is important in hypoglycemia, it is not a direct nursing intervention. Choice D is incorrect as providing insulin would lower blood sugar levels further, worsening hypoglycemia.

3. A client who had a vaginal delivery 4 hours ago has a fourth-degree perineal laceration. Which of the following interventions should the nurse recommend?

• A. Encourage ambulation
• B. Apply ice packs
• C. Restrict the client's fluid intake
• D. Administer stool softeners

Correct answer: B

Rationale: Correct Answer: Applying ice packs is the most appropriate intervention for a client with a fourth-degree perineal laceration. Ice packs help reduce swelling and promote comfort, aiding in the healing process. Choice A, encouraging ambulation, may not be suitable immediately after a fourth-degree laceration due to the need for rest and proper wound care. Choice C, restricting fluid intake, is not indicated and can lead to dehydration, which is not beneficial for wound healing. Choice D, administering stool softeners, may be necessary to prevent constipation and straining, but it is not the priority intervention at this time.

4. A nurse is collecting data from an older adult client during a routine physical examination. Which of the following client statements should the nurse identify as a possible indication of maltreatment?

• A. My son took my wallet to keep track of my spending
• B. My son always cooks my meals for me
• C. My son doesn't want me to drive alone
• D. I exercise every day with my son

Correct answer: A

Rationale: The correct answer is A. Taking away a wallet to control spending is a form of financial maltreatment, which is a common form of abuse among older adults. Choices B, C, and D do not indicate maltreatment; rather, they show examples of care and concern from the son. Cooking meals, preventing the older adult from driving alone, and engaging in daily exercise are positive behaviors.

5. Which of the following is a realistic short-term goal to be accomplished in 2 to 3 days for a client with delirium?

• A. Explain the experience of having delirium
• B. Resume a normal sleep-wake cycle
• C. Regain orientation to time and place
• D. Establish normal bowel and bladder function

Correct answer: C

Rationale: Regaining orientation to time and place is a realistic short-term goal for clients with delirium. It helps the individual become aware of their surroundings and current situation, aiding in reducing confusion and disorientation. Choice A is incorrect because the goal is focused on the client's understanding, not on explaining the experience of delirium. Choice B, resuming a normal sleep-wake cycle, may take longer than 2 to 3 days to achieve and is not directly related to regaining orientation. Choice D, establishing normal bowel and bladder function, is important but may not be a short-term goal specifically related to delirium.

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