Nursing Elites

1. A client who has a flaccid bladder is placed on a bladder training program. Which instruction should the nurse include in this client's teaching plan?

• A. Use manual pressure to express urine
• B. Perform the Crede maneuver
• C. Apply an external urinary drainage device
• D. Take a warm sitz bath twice a day

Correct answer: B

Rationale: The correct answer is B: Perform the Crede maneuver. The Crede maneuver is a technique used to manage a flaccid bladder by applying manual pressure over the bladder area to assist in the expulsion of urine. This technique helps promote bladder emptying. Choice A is incorrect because using manual pressure to express urine is not a standardized technique and may cause harm. Choice C is incorrect as applying an external urinary drainage device does not address the need for bladder training. Choice D is unrelated to bladder training for a flaccid bladder.

2. A client who is 32-weeks pregnant is diagnosed with partial placenta previa. Which instruction should the nurse include in this client’s teaching plan?

• A. Wear a tight abdominal binder at all times
• B. Take a daily laxative to prevent constipation
• C. Refrain from sexual intercourse until your next appointment
• D. Restrict fluids to less than 1000 ml per day

Correct answer: C

Rationale: Refraining from sexual intercourse helps prevent complications with partial placenta previa.

3. A client with cirrhosis is taking lactulose (Cephulac). Which finding indicates that the lactulose is having the desired effect?

• A. Two to three soft bowel movements per day
• B. Increased serum ammonia levels
• C. Decreased white blood cell count
• D. Soft, formed stool twice a day

Correct answer: A

Rationale: The correct answer is A: 'Two to three soft bowel movements per day.' Lactulose is prescribed to produce soft, regular bowel movements to reduce ammonia levels in clients with cirrhosis. This helps in preventing hepatic encephalopathy. Option B is incorrect because increased serum ammonia levels would indicate that lactulose is not effectively reducing ammonia levels. Option C is incorrect because lactulose does not directly affect white blood cell counts. Option D is incorrect because soft, formed stools twice a day may not be frequent enough to effectively reduce ammonia levels in clients with cirrhosis.

4. The nurse is planning a health fair for young adults. Which action is most important for the nurse to implement?

• A. Provide educational materials on smoking cessation
• B. Offer blood pressure screening and monitoring
• C. Provide information on safe sex practices
• D. Discuss the importance of a healthy diet and exercise

Correct answer: B

Rationale: Offering blood pressure screening and monitoring is crucial for young adults as it helps in the early detection and management of hypertension, a condition that often goes unnoticed. High blood pressure can lead to serious health issues if left untreated. While education on smoking cessation, safe sex practices, healthy diet, and exercise are important aspects of overall health promotion, blood pressure screening takes precedence due to its immediate impact on health and the prevention of potential complications.

5. The nurse is triaging clients from a train wreck. A client has multiple open wounds, a blood pressure of 90/56, and a pulse of 112 beats/minute. Which triage tag color should the nurse place on this client?

• A. Black
• B. Yellow
• C. Green
• D. Red

Correct answer: D

Rationale: The correct answer is D: Red. The client's vital signs indicate critical condition with a high pulse and low blood pressure, suggesting shock. A red tag is used to identify patients who require immediate attention and should be prioritized for treatment. Choice A, Black, is incorrect as it is typically used for deceased or expectant clients. Choice B, Yellow, is used for clients with non-life-threatening injuries who require medical care but can wait. Choice C, Green, is for clients with minor injuries who can wait the longest for treatment. Therefore, in this scenario, the client's condition warrants a red triage tag for immediate attention.

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