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 healthcare professional is reviewing the laboratory values of a client who is experiencing fluid volume deficit (FVD). What finding should the professional expect?

• A. Decreased hematocrit
• B. Increased hematocrit
• C. Decreased white blood cell count
• D. Increased red blood cell count

Correct answer: B

Rationale: The correct answer is 'Increased hematocrit.' In fluid volume deficit (FVD), there is a decrease in the amount of fluid in the blood vessels, leading to hemoconcentration. This results in an increase in hematocrit levels. Choices A, C, and D are incorrect because a decrease in hematocrit, decrease in white blood cell count, and an increase in red blood cell count are not typically seen in fluid volume deficit.

3. A nurse is assessing a client who is at risk for pressure injuries. Which intervention should the nurse include in the plan of care?

• A. Reposition the client every 4 hours
• B. Use a special mattress for the client
• C. Keep the client on bedrest
• D. Encourage the client to remain in one position

Correct answer: B

Rationale: The correct answer is B: 'Use a special mattress for the client.' Using a special mattress reduces pressure on bony prominences and helps prevent pressure injuries. Repositioning the client every 4 hours (choice A) is important but using a special mattress is more effective. Keeping the client on bedrest (choice C) can increase the risk of pressure injuries due to prolonged immobility. Encouraging the client to remain in one position (choice D) is incorrect as it can lead to pressure injuries by exerting pressure on the same areas for an extended period.

4. A client who is postoperative following abdominal surgery is at risk for constipation due to which behavior?

• A. Increased fiber intake
• B. Decreased fluid intake
• C. Frequent urge suppression
• D. Increased physical activity

Correct answer: B

Rationale: Postoperative clients are at risk for constipation due to various factors, including decreased fluid intake. Insufficient fluid consumption can lead to hardening of stools, making them difficult to pass. Increased fiber intake (choice A) is actually beneficial for preventing constipation as it adds bulk to the stool. Frequent urge suppression (choice C) can contribute to constipation by disrupting normal bowel habits. Increased physical activity (choice D) generally helps promote bowel movements and reduce the risk of constipation.

5. A nurse is caring for a client who reports burning around the peripheral IV site. What finding should the nurse identify as a manifestation of infiltration?

• A. Bruising at the IV site
• B. Edema at the IV site
• C. Warmth along the IV site
• D. Pallor at the IV site

Correct answer: B

Rationale: Edema at the IV site is a common sign of infiltration, where fluid leaks into the surrounding tissue. Bruising at the IV site (Choice A) is more indicative of hematoma formation, warmth along the IV site (Choice C) may suggest infection, and pallor at the IV site (Choice D) is not a typical sign of infiltration.

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