Nursing Elites

1. A nurse is caring for a client who has an indwelling urinary catheter. What should the nurse identify as a sign of catheter occlusion?

• A. Bladder spasms
• B. Bladder distention
• C. Frequent urination
• D. Hematuria

Correct answer: B

Rationale: The correct answer is B: Bladder distention. Bladder distention is a sign of catheter occlusion because it indicates a failure to drain urine properly. Bladder spasms (Choice A) are more commonly associated with bladder irritability rather than catheter occlusion. Frequent urination (Choice C) is unlikely in a client with an indwelling catheter as the urine should be draining continuously. Hematuria (Choice D) refers to blood in the urine and is not typically a direct sign of catheter occlusion.

2. A nurse is preparing to perform a routine abdominal assessment for a client. Which action should the nurse take?

• A. Palpate the abdomen before auscultation
• B. Inspect the abdomen after palpation
• C. Auscultate before palpation
• D. Start by percussing the abdomen

Correct answer: C

Rationale: The correct answer is to auscultate before palpation when performing an abdominal assessment. This sequence is crucial to prevent altering bowel sounds. Starting with palpation (Choice A) can lead to false interpretations of bowel sounds due to stimulation of the intestines. Inspecting the abdomen after palpation (Choice B) can also potentially alter the assessment findings. Starting with percussion (Choice D) is not recommended as it should come after auscultation to further assess underlying structures.

3. A nurse is reviewing a client's health history and identifies urinary incontinence as a risk factor for pressure injuries. What should the nurse include in the plan of care?

• A. Use a heating pad for comfort
• B. Apply a barrier cream to the skin
• C. Reposition the client every 4 hours
• D. Change the client's position every 2 hours

Correct answer: C

Rationale: The correct answer is to reposition the client every 4 hours. Repositioning the client helps prevent pressure injuries caused by urinary incontinence by relieving pressure on vulnerable areas of the skin. Choice A, using a heating pad for comfort, is not directly related to preventing pressure injuries. Choice B, applying a barrier cream to the skin, may help protect the skin but does not address the underlying cause of pressure injuries. Choice D, changing the client's position every 2 hours, is more frequent than necessary and may not be as effective in preventing pressure injuries as repositioning every 4 hours.

4. A healthcare professional is preparing to administer an intramuscular injection to a client. What is the appropriate site for the injection to avoid injury?

• A. Deltoid
• B. Ventrogluteal
• C. Rectus femoris
• D. Dorsogluteal

Correct answer: B

Rationale: The ventrogluteal site is the preferred site for intramuscular injections to avoid injury to nerves or blood vessels. The deltoid site is commonly used for vaccines but has a higher risk of hitting the radial nerve. The rectus femoris site is not typically recommended for intramuscular injections. The dorsogluteal site is contraindicated due to the proximity to the sciatic nerve and major blood vessels.

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

• A. Decrease potassium intake
• B. Increase fluid intake to 2 liters per day
• C. Avoid foods high in calcium
• D. Increase sodium intake

Correct answer: B

Rationale: The correct lifestyle modification that the nurse should emphasize for a client with hypertension is to increase fluid intake to 2 liters per day. Proper hydration helps manage hypertension by supporting kidney function in regulating blood pressure and by diluting sodium levels in the body. Decreasing potassium intake (Choice A) is not recommended, as potassium-rich foods like fruits and vegetables are beneficial for blood pressure control. Avoiding foods high in calcium (Choice C) is not directly related to managing hypertension, and increasing sodium intake (Choice D) is contraindicated as excess sodium can elevate blood pressure.

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