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 healthcare professional is teaching a client about the use of a metered-dose inhaler (MDI). Which instruction should the professional include?

• A. Inhale for 1 second
• B. Shake the inhaler vigorously
• C. Hold the inhaler 5-7 cm away from the mouth
• D. Hold breath for 5 seconds after inhalation

Correct answer: B

Rationale: The correct instruction when using a metered-dose inhaler (MDI) is to shake the inhaler vigorously before use. Shaking the inhaler ensures proper mixing of the medication, which is crucial for effective delivery of the medication into the lungs. Inhaling for a specific duration, holding the inhaler at a certain distance from the mouth, or holding the breath after inhalation are not as critical as ensuring proper mixing of the medication by shaking the inhaler.

3. When teaching a client about the correct use of a cane, what should the nurse include?

• A. Hold the cane on the weaker side
• B. Ensure the cane has a rubber tip
• C. Keep the cane on the dominant side
• D. Use the cane only on stairs

Correct answer: B

Rationale: The correct answer is B. When instructing a client on the use of a cane, it is essential to ensure that the cane has a rubber tip. This rubber tip helps prevent slipping, providing additional stability and safety. Option A, holding the cane on the weaker side, is incorrect as the cane should be held on the stronger side to provide better balance and support. Option C, keeping the cane on the dominant side, is also incorrect because the cane should be held on the stronger side. Option D, using the cane only on stairs, is not comprehensive as the cane can be used for support and balance while walking on level ground as well.

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

• A. Frequent repositioning
• B. Poor nutrition
• C. Increased fluid intake
• D. Use of a special mattress

Correct answer: B

Rationale: Corrected Rationale: Poor nutrition increases the risk of developing pressure injuries as it impairs skin integrity and healing. Frequent repositioning, increased fluid intake, and the use of a special mattress are all important interventions for preventing pressure injuries, rather than risk factors for developing them. Repositioning helps relieve pressure, adequate fluid intake maintains skin hydration, and special mattresses redistribute pressure to prevent injuries.

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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