Nursing Elites

1. A client is being assessed for dehydration. Which of the following findings should the nurse expect?

• A. Elevated blood pressure
• B. Increased skin turgor
• C. Dark-colored urine
• D. Bradypnea

Correct answer: C

Rationale: Dark-colored urine is a common sign of dehydration as the urine becomes concentrated. Dehydration leads to reduced fluid intake or excessive fluid loss, causing the urine to be darker in color due to increased urine concentration. Elevated blood pressure (Choice A) is not typically associated with dehydration; instead, dehydration often leads to low blood pressure. Increased skin turgor (Choice B) is actually a sign of good hydration, not dehydration. Bradypnea (Choice D), which refers to abnormally slow breathing, is not a common finding in dehydration.

2. Which of the following techniques should be used to insert an indwelling urinary catheter for a female client?

• A. Use sterile technique.
• B. Insert the catheter 2-3 inches into the urethra.
• C. Inflate the balloon after insertion.
• D. Lubricate the catheter tip before insertion.

Correct answer: D

Rationale: Lubricating the catheter tip before insertion is crucial for female urinary catheterization. This step helps reduce discomfort for the patient and facilitates smooth catheter insertion into the urethra. Using sterile technique maintains asepsis during the procedure, inserting the catheter 2-3 inches ensures proper placement, and inflating the balloon after insertion secures the catheter in place without causing trauma. Proper technique is fundamental for patient comfort, preventing infection, and ensuring the success of the catheterization procedure.

3. A healthcare professional is preparing to administer a cleansing enema to a client. Which of the following actions should the healthcare professional plan to take?

• A. Insert the rectal tube 15.2 cm (6 inches) into the client's rectum
• B. Wear clean gloves before inserting the tubing
• C. Position the client on their left side
• D. Hold the solution bag 91 cm (36 inches) above the client's rectum

Correct answer: C

Rationale: Positioning the client on their left side is crucial when administering an enema as it helps facilitate the flow of the solution into the sigmoid and descending colon. This position allows gravity to assist in the process. Placing the client on the left side is a standard practice to promote optimal outcomes during the procedure. Choices A, B, and D are incorrect. Choice A provides a specific measurement for the insertion depth of the rectal tube, which is not typically necessary to include in the plan of action. Choice B is essential but not specific to enema administration. Choice D mentions holding the solution bag without specifying the correct height, which should typically be around 18-24 inches above the rectum for a cleansing enema.

4. What action should be taken to prevent respiratory complications in a client who is postoperative?

• A. Encourage the use of an incentive spirometer.
• B. Restrict fluid intake.
• C. Place the client in a supine position.
• D. Administer a cough suppressant.

Correct answer: A

Rationale: Encouraging the use of an incentive spirometer is crucial in preventing respiratory complications postoperatively. The incentive spirometer helps the client perform deep breathing exercises, which can prevent atelectasis (lung collapse) and promote lung expansion. This, in turn, reduces the risk of respiratory complications such as pneumonia. Restricting fluid intake, placing the client in a supine position, and administering a cough suppressant are not appropriate actions for preventing respiratory complications in a postoperative client.

5. A client has a new diagnosis of hypertension, and the nurse is teaching them about the DASH diet. Which of the following statements should the nurse include in the teaching?

• A. You should increase your intake of sodium-rich foods.
• B. You should decrease your intake of potassium-rich foods.
• C. You should increase your intake of fruits and vegetables.
• D. You should decrease your intake of whole grains.

Correct answer: C

Rationale: The DASH diet, recommended for managing hypertension, emphasizes increasing the intake of fruits and vegetables. These food groups are rich in essential nutrients, fiber, and antioxidants, which can help lower blood pressure levels and promote overall cardiovascular health.

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