Nursing Elites

1. A nurse is assessing a client who reports pain 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. Administer prescribed antibiotics
• D. Assess for signs of infection

Correct answer: B

Rationale: When a client reports pain at the site of an indwelling urinary catheter, the nurse's first action should be to notify the provider. This is important to ensure timely assessment and intervention by the healthcare provider. Irrigating the catheter with normal saline or administering antibiotics should not be done without provider's orders as it may mask symptoms or lead to inappropriate treatment. Assessing for signs of infection is important but should come after notifying the provider, who can guide further assessment and treatment.

2. A client with diabetes mellitus is receiving discharge instructions about foot care from a nurse. Which statement indicates an understanding of the teaching?

• A. I will soak my feet in hot water daily
• B. I will wear shoes at all times
• C. I will cut my toenails in a rounded shape
• D. I will apply lotion between my toes after bathing

Correct answer: B

Rationale: The correct answer is B: 'I will wear shoes at all times.' This statement demonstrates an understanding of foot care for a client with diabetes. Wearing shoes at all times helps protect the feet, reducing the risk of injury and complications such as wounds or infections. Option A is incorrect because soaking feet in hot water can lead to skin dryness and increase the risk of burns or injury for individuals with diabetes. Option C is incorrect as cutting toenails in a rounded shape can cause ingrown toenails and potential infections. Option D is also incorrect as applying lotion between the toes can create a moist environment, increasing the risk of fungal infections.

3. A client is being taught by a nurse about the correct use of a metered-dose inhaler (MDI). What instruction should the nurse include?

• A. Inhale for 1 second
• B. Hold the inhaler 1-2 inches from the mouth
• C. Exhale immediately after inhaling
• D. Hold the inhaler directly at the lips

Correct answer: B

Rationale: The correct instruction the nurse should include when teaching a client about using a metered-dose inhaler (MDI) is to hold the inhaler 1-2 inches from the mouth. This distance ensures proper delivery of the medication into the airways. Choices A, C, and D are incorrect because inhaling for a specific duration, exhaling immediately after inhaling, or holding the inhaler directly at the lips are not recommended practices for the correct use of an MDI.

4. A healthcare professional is reviewing the health history of a client who has a hip fracture. What is a risk factor for developing pressure injuries?

• A. Increased fluid intake
• B. Urinary incontinence
• C. Poor nutrition
• D. Immobility

Correct answer: B

Rationale: Urinary incontinence is a risk factor for developing pressure injuries as it can lead to skin breakdown due to constant exposure to moisture and irritation. Increased fluid intake is important for hydration and overall health but is not directly linked to pressure injuries. Poor nutrition can impair wound healing but is not a direct risk factor for pressure injuries. Immobility can contribute to the development of pressure injuries but is not as directly related as urinary incontinence.

5. A client is reviewing a medical record for advance directives. Which client statement indicates an understanding of the teaching?

• A. I don't need a living will because my family will make decisions.
• B. My living will takes effect only if I lose consciousness.
• C. My family will decide when to follow my living will.
• D. I can change my living will at any time.

Correct answer: D

Rationale: The correct answer is D because clients can change their living will at any time as long as they are mentally competent. Choice A is incorrect because relying solely on family to make decisions may not align with the client's wishes. Choice B is incorrect because a living will can address various situations, not just loss of consciousness. Choice C is incorrect because the client should be the primary decision-maker regarding their living will, not the family.

Similar Questions