Nursing Elites

1. A nurse is caring for a client who has Crohn's disease. Which of the following findings should the nurse expect?

• A. Weight gain.
• B. Bloody stools.
• C. Urinary retention.
• D. Abdominal distention.

Correct answer: B

Rationale: The correct answer is B: Bloody stools. Bloody stools are a common symptom of Crohn's disease, characterized by inflammation of the digestive tract. Weight gain (choice A) is less likely due to malabsorption issues associated with Crohn's disease. Urinary retention (choice C) is not directly related to Crohn's disease. Abdominal distention (choice D) may occur in Crohn's disease but is not as specific a finding as bloody stools.

2. A nurse is assessing a client who has just received an opioid medication. Which of the following findings should the nurse monitor first?

• A. Constipation.
• B. Drowsiness.
• C. Orthostatic hypotension.
• D. Respiratory depression.

Correct answer: D

Rationale: When a client receives an opioid medication, the nurse should first monitor for respiratory depression as it is a life-threatening adverse effect associated with opioids. This can lead to inadequate ventilation and hypoxia, requiring immediate intervention. Constipation, drowsiness, and orthostatic hypotension are also common side effects of opioids but are not as immediately life-threatening as respiratory depression.

3. A nurse is caring for a client who has a fecal impaction. Which action should the nurse take when digitally evacuating the stool?

• A. Insert a lubricated gloved finger and advance along the rectal wall
• B. Apply lubricant and stimulate peristalsis
• C. Apply pressure to the abdomen to assist with removal
• D. Increase fluid intake before the procedure

Correct answer: A

Rationale: The correct action when digitally evacuating a fecal impaction is to insert a lubricated gloved finger and advance along the rectal wall. This technique helps prevent trauma and effectively dislodge the impacted stool. Choice B, applying lubricant and stimulating peristalsis, is incorrect as it does not directly address the evacuation of the impacted stool. Choice C, applying pressure to the abdomen, is inappropriate and may cause discomfort or harm to the client. Choice D, increasing fluid intake before the procedure, is not directly related to the immediate evacuation of the fecal impaction.

4. A nurse is preparing to insert an indwelling urinary catheter for a female client. Which of the following actions should the nurse take?

• A. Perform perineal care before the procedure.
• B. Apply sterile gloves before cleansing the perineal area.
• C. Place the client in a supine position.
• D. Lubricate the catheter with alcohol-based gel.

Correct answer: B

Rationale: Before inserting an indwelling urinary catheter for a female client, the nurse should apply sterile gloves before cleansing the perineal area to prevent infection. Performing perineal care before the procedure is incorrect as it should be done after catheter insertion. Placing the client in a side-lying position is not necessary for this procedure. Lubricating the catheter with petroleum jelly is not recommended as it can damage the catheter; using a water-soluble lubricant is preferred.

5. A nurse is providing teaching to a client who is at 36 weeks of gestation and is scheduled for a nonstress test. Which of the following instructions should the nurse include?

• A. The test will last about 30 minutes.
• B. You should drink a full glass of water prior to the test.
• C. You will need to have your bladder full for this test.
• D. This test measures how well your baby's heart responds to movement.

Correct answer: D

Rationale: The correct answer is D. A nonstress test measures the fetal heart's response to movement, helping to assess fetal well-being. Choice A is incorrect as the duration of the test can vary, and it is not always precisely 30 minutes. Choice B is incorrect as drinking water is not necessary for a nonstress test. Choice C is incorrect as having a full bladder is not required for this test.

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