Nursing Elites

1. A client has been sitting in a chair for 1 hour. Which of the following complications poses the greatest risk to the client?

• A. Decreased subcutaneous fat
• B. Muscle atrophy
• C. Pressure injury
• D. Fecal impaction

Correct answer: C

Rationale: The correct answer is C: Pressure injury. Prolonged sitting can lead to pressure injuries due to continuous pressure on certain body areas, reducing blood flow and causing tissue damage. While decreased subcutaneous fat, muscle atrophy, and fecal impaction are potential concerns, pressure injuries pose the greatest immediate risk as they can lead to serious complications such as tissue necrosis and infection if not addressed promptly. Decreased subcutaneous fat and muscle atrophy may develop over time with prolonged immobility but are not as acutely dangerous as a pressure injury. Fecal impaction, while uncomfortable and potentially serious, does not pose an immediate life-threatening risk compared to the development of a pressure injury.

2. A post-op nurse has an indwelling catheter in place for gravity drainage. The nurse notes that the client's urine bag has been empty for 2 hours. The first action the nurse should take is to:

• A. Check to see if the tubing is kinked.
• B. Increase the IV fluid rate.
• C. Check the catheter insertion site.
• D. Contact the healthcare provider.

Correct answer: A

Rationale: The correct action for the nurse to take when the urine bag has not filled for 2 hours is to check if the tubing is kinked. Kinks in the tubing can obstruct the flow of urine from the catheter, leading to decreased drainage. Increasing the IV fluid rate is not the appropriate initial action in this situation as the primary concern is with the catheter drainage. Checking the catheter insertion site would be secondary to ensuring proper drainage. Contacting the healthcare provider is not necessary as the issue can often be resolved by checking for simple tubing obstructions first.

3. A client is scheduled for a bronchoscopy. After the nurse explains the procedure, which statement by the client indicates a need for further teaching?

• A. I'm glad I don’t have to lie still for this procedure.
• B. I will have a local anesthetic to help with discomfort.
• C. I hope I get some medicine to relax me.
• D. I can't eat or drink for 6 hours before the procedure.

Correct answer: A

Rationale: The correct answer is A because the client's statement indicates a misunderstanding about the need to lie still during the bronchoscopy procedure. The client actually needs to remain still for the procedure to ensure its accuracy and safety. Choices B, C, and D demonstrate an understanding of the procedure by acknowledging the local anesthetic for discomfort, the possibility of receiving medicine for relaxation, and the requirement to fast before the procedure, respectively.

4. The healthcare provider is assessing a client with acute pancreatitis. Which finding is most concerning?

• A. Pain radiating to the back
• B. Blood pressure of 95/60 mmHg
• C. Elevated serum amylase
• D. Absent bowel sounds

Correct answer: B

Rationale: In acute pancreatitis, a low blood pressure of 95/60 mmHg is the most concerning finding as it may indicate hypovolemia or shock, which are critical conditions requiring immediate intervention. Pain radiating to the back is a common symptom of pancreatitis but is not as immediately life-threatening as hypotension. Elevated serum amylase levels and absent bowel sounds are typical findings in acute pancreatitis and may indicate pancreatic inflammation and gastrointestinal motility issues, respectively, but they are not as acutely concerning as hypotension.

5. When teaching a client how to administer medication through a jejunostomy tube, which of the following instructions should the nurse include?

• A. Flush the tube before and after each medication.
• B. Mix medications with enteral feeding.
• C. Push tablets through the tube slowly.
• D. Mix crushed medications before dissolving them in water.

Correct answer: A

Rationale: The correct answer is to flush the tube before and after each medication administration. This helps prevent clogging and ensures the medication is delivered properly. Mixing medications with enteral feeding (choice B) is incorrect as medications should be administered separately. Pushing tablets through the tube (choice C) is not recommended as they should be properly dissolved before administration. Mixing all crushed medications before dissolving them in water (choice D) is incorrect; medications should be dissolved individually to avoid interactions or inconsistencies in dosages.

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