Nursing Elites

1. A client with an indwelling urinary catheter is being cared for by a nurse. What finding indicates a catheter occlusion?

• A. Bladder distention
• B. Frequent urination
• C. Hematuria
• D. Burning sensation

Correct answer: A

Rationale: Bladder distention is the correct answer as it indicates that the catheter is not draining properly, which is a sign of occlusion. Frequent urination, hematuria, and burning sensation are not indicative of a catheter occlusion. Frequent urination may suggest a bladder that is not fully emptying, hematuria indicates blood in the urine, and a burning sensation can be a sign of a urinary tract infection, none of which directly relate to a catheter occlusion.

2. When admitting a client with meningococcal meningitis, what should the nurse do first?

• A. Administer antibiotics
• B. Place the client on droplet precautions
• C. Perform a lumbar puncture
• D. Initiate seizure precautions

Correct answer: B

Rationale: When admitting a client with meningococcal meningitis, the nurse's priority should be to place the client on droplet precautions. This is crucial to prevent the spread of the infection to others. Administering antibiotics, performing a lumbar puncture, and initiating seizure precautions are important interventions but should come after implementing droplet precautions to ensure the safety of both the client and others.

3. A nurse is caring for a client who reports a decrease in the effectiveness of their arthritis medication. What factor should the nurse identify as contributing to this decrease?

• A. Improved mobility
• B. Bowel inflammation
• C. Long-term use of the medication
• D. Frequent dehydration

Correct answer: B

Rationale: The correct answer is B: Bowel inflammation. Bowel inflammation can decrease the absorption of medications, reducing their effectiveness. Improved mobility (choice A) would generally not contribute to a decrease in medication effectiveness. Long-term use of the medication (choice C) may lead to tolerance but would not directly cause a decrease in effectiveness. Frequent dehydration (choice D) can affect overall health but is not a direct factor in the medication's effectiveness for arthritis.

4. A nurse is updating the plan of care for a client with limited mobility. What intervention should the nurse include to prevent skin breakdown?

• A. Reposition the client every 4 hours
• B. Apply lotion to the skin every 2 hours
• C. Use a special mattress to reduce pressure on the skin
• D. Increase fluid intake to promote skin hydration

Correct answer: C

Rationale: The correct answer is C: 'Use a special mattress to reduce pressure on the skin.' This intervention is crucial in preventing skin breakdown in clients with limited mobility as it helps to reduce pressure on bony prominences. Repositioning every 4 hours (Choice A) is important but may not be sufficient to prevent skin breakdown entirely. Applying lotion every 2 hours (Choice B) may not address the root cause of skin breakdown related to pressure. Increasing fluid intake (Choice D) is beneficial for overall skin health but may not directly prevent skin breakdown caused by pressure points.

5. While assessing the IV infusion site of a client experiencing pain, redness, and warmth, what should the nurse do?

• A. Increase the IV flow rate
• B. Discontinue the infusion
• C. Elevate the limb
• D. Apply a cold compress

Correct answer: B

Rationale: The correct answer is to discontinue the infusion. Pain, redness, and warmth at the IV site are signs of phlebitis, which is inflammation of the vein. Continuing the infusion can further irritate the vein and lead to complications. Increasing the IV flow rate would exacerbate the issue by delivering more irritants to the vein. Elevating the limb and applying a cold compress are not the appropriate interventions for phlebitis, as discontinuing the infusion is crucial to prevent further harm.

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