Nursing Elites

1. A nurse in an acute care facility is caring for a client who is postop following abdominal surgery. Which behavior should the nurse identify as increasing the client's risk for constipation?

• A. Increased physical activity
• B. Frequent urge suppression
• C. Increased fiber intake
• D. Decreased fluid intake

Correct answer: B

Rationale: Frequent urge suppression can lead to constipation, especially postoperatively. Suppressing the urge to defecate can disrupt normal bowel movements and result in constipation. Increased physical activity, increased fiber intake, and adequate fluid intake are measures that typically help prevent constipation by promoting bowel regularity and preventing stool hardening. Therefore, choices A, C, and D are not behaviors that increase the client's risk for constipation.

2. A nurse is assessing a client who reports pain and tenderness at the site of an indwelling urinary catheter. What is the nurse's first action?

• A. Irrigate the catheter with normal saline
• B. Notify the provider
• C. Assess for signs of infection
• D. Administer prescribed antibiotics

Correct answer: B

Rationale: The correct first action for the nurse to take when a client reports pain and tenderness at the site of an indwelling urinary catheter is to notify the provider. Pain and tenderness at the catheter site may indicate infection, and the healthcare provider needs to be informed for further assessment and appropriate interventions. Irrigating the catheter with normal saline (Choice A) should not be the initial action without consulting the provider first. While assessing for signs of infection (Choice C) is important, notifying the provider takes precedence. Administering prescribed antibiotics (Choice D) should only be done based on the provider's orders after assessment and confirmation of infection.

3. A client with diabetes mellitus is being taught about foot care by a nurse. Which instruction should the nurse include?

• A. Cut toenails straight across
• B. Wear shoes at all times
• C. Apply lotion between the toes
• D. Soak feet in hot water daily

Correct answer: B

Rationale: The correct answer is to 'Wear shoes at all times.' This instruction is crucial for preventing foot injuries in clients with diabetes mellitus. Wearing shoes protects the feet from potential injuries and reduces the risk of developing foot ulcers. Cutting toenails straight across (not in a rounded shape) helps prevent ingrown toenails. Applying lotion between the toes can create a moist environment, increasing the risk of fungal infections. Soaking feet in hot water daily can lead to dry skin and potentially cause burns, which is not recommended for individuals with diabetes.

4. A nurse is assessing a client who reports pain at the site of a peripheral IV. The site is red and warm. What is the nurse's priority action?

• A. Flush the IV line with saline
• B. Discontinue the IV infusion
• C. Apply a cold compress
• D. Increase the IV flow rate

Correct answer: B

Rationale: The correct answer is to discontinue the IV infusion. The signs of redness and warmth at the IV site indicate phlebitis, an inflammation of the vein. Discontinuing the IV infusion is crucial to prevent further complications such as infection or thrombosis. Flushing the IV line with saline would not address the underlying issue of phlebitis. Applying a cold compress may provide temporary relief but does not address the cause. Increasing the IV flow rate can exacerbate the inflammation and should be avoided.

5. A nurse is preparing to administer a medication to a client with a nasogastric (NG) tube. What action should the nurse take?

• A. Administer the medication with a straw
• B. Flush the NG tube with 30 mL of water before administration
• C. Crush all medications together
• D. Mix the medication with pudding

Correct answer: B

Rationale: The correct action for the nurse to take when administering medication to a client with a nasogastric (NG) tube is to flush the NG tube with 30 mL of water before administration. Flushing the tube with water helps ensure the patency of the tube and prevents clogging. Choice A is incorrect because administering the medication with a straw is not a recommended practice for NG tube administration. Choice C is incorrect because crushing all medications together may lead to potential drug interactions. Choice D is incorrect because mixing the medication with pudding is not a standard method for administering medication through an NG tube.

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