Nursing Elites

1. A nurse is caring for a client who has an indwelling urinary catheter. What finding indicates a catheter occlusion?

• A. Bladder distention
• B. Bladder spasms
• C. Hematuria
• D. Increased urine output

Correct answer: A

Rationale: Bladder distention is the correct finding that indicates a catheter occlusion. When the catheter is occluded, urine cannot drain properly, leading to the build-up of urine in the bladder, causing distention. Bladder spasms (Choice B) are not typically associated with catheter occlusion but may indicate irritation or infection. Hematuria (Choice C) refers to blood in the urine and is not specific to catheter occlusion. Increased urine output (Choice D) is not indicative of catheter occlusion but may suggest other conditions like diabetes insipidus.

2. A nurse is monitoring a client who is receiving continuous enteral feedings. What is a sign of intolerance to the feeding?

• A. Weight gain
• B. Nausea
• C. Constipation
• D. Decreased heart rate

Correct answer: B

Rationale: Nausea is a common sign of intolerance to enteral feedings and should be addressed promptly. Weight gain (Choice A) is not typically a sign of intolerance to enteral feedings but may indicate other health issues. Constipation (Choice C) is not a common sign of feeding intolerance. Decreased heart rate (Choice D) is not typically associated with intolerance to enteral feedings.

3. A healthcare professional is reviewing the medical record of a client with a hip fracture. Which finding is a risk factor for pressure injuries?

• A. Frequent repositioning
• B. Poor nutrition
• C. Use of a special mattress
• D. Urinary incontinence

Correct answer: C

Rationale: The correct answer is the use of a special mattress. Special mattresses are designed to reduce pressure on bony prominences, thereby helping to prevent pressure injuries. Frequent repositioning (Choice A) is actually a preventive measure for pressure injuries. Poor nutrition (Choice B) can contribute to delayed wound healing but is not a direct risk factor for pressure injuries. Urinary incontinence (Choice D) can increase the risk of skin breakdown but is not a direct risk factor for pressure injuries.

4. A nurse is teaching a client with diabetes mellitus about foot care. What is the most important instruction the nurse should include?

• A. Apply lotion between the toes after bathing
• B. Inspect feet daily for injuries
• C. Wear shoes only indoors
• D. Cut toenails in a rounded shape

Correct answer: B

Rationale: Inspecting feet daily for injuries is crucial for clients with diabetes to prevent unnoticed wounds from becoming infected. This instruction is the most important as it helps in early detection and management of foot problems. Choice A is incorrect because applying lotion between the toes can lead to excessive moisture, increasing the risk of fungal infections. Choice C is wrong as wearing shoes indoors can also lead to foot issues. Choice D is incorrect because cutting toenails in a rounded shape can result in ingrown toenails, posing a risk for infection.

5. A nurse is providing discharge teaching to a client with a new diagnosis of hypertension. What instruction should the nurse include?

• A. Reduce sodium intake to 4 grams per day
• B. Avoid foods high in potassium
• C. Take prescribed antihypertensive medications daily
• D. Limit fluid intake to 1 liter per day

Correct answer: C

Rationale: The correct answer is C: 'Take prescribed antihypertensive medications daily.' When providing discharge teaching to a client with hypertension, one of the key instructions is to ensure the consistent intake of prescribed antihypertensive medications. This is crucial for controlling blood pressure levels and reducing the risk of complications associated with hypertension. Choices A, B, and D are incorrect because reducing sodium intake, avoiding foods high in potassium, and limiting fluid intake are important dietary modifications for various health conditions, but they are not the priority when it comes to managing hypertension. The primary focus should be on medication adherence to effectively manage hypertension.

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