Nursing Elites

1. A nurse is caring for a female client who has an indwelling urinary catheter. Which of the following actions should the nurse take?

• A. Position the drainage bag below the bladder
• B. Wipe the drainage port after emptying
• C. Insert the catheter using sterile technique
• D. Avoid cleansing the urinary meatus

Correct answer: B

Rationale: The correct answer is to wipe the drainage port after emptying. This action helps reduce the risk of infection by maintaining cleanliness. Positioning the drainage bag below the bladder (choice A) is incorrect as it should be positioned below the level of the bladder to prevent backflow of urine. Inserting the catheter using sterile technique (choice C) is not necessary for routine emptying of the drainage bag. Avoiding cleansing the urinary meatus (choice D) is incorrect as proper hygiene should be maintained to prevent infections.

2. A nurse is observing an assistive personnel (AP) apply antiembolic stockings for a client. Which of the following actions by the AP demonstrates an understanding of how to perform this skill?

• A. Apply the stocking while the client is seated
• B. Apply the stocking before the client gets out of bed
• C. Use lotion under the stocking to ease application
• D. Bunch the stocking around the heel before applying

Correct answer: B

Rationale: The correct answer is B. Applying antiembolic stockings before the client gets out of bed is crucial as it helps prevent venous stasis and clot formation. Choice A is incorrect because stockings should be applied before the client gets out of bed. Choice C is incorrect as using lotion under the stocking can cause the stocking to slip. Choice D is incorrect because the stocking should be smooth and not bunched to prevent pressure points.

3. A client with type 2 diabetes mellitus is concerned about weight gain during pregnancy. Which of the following responses should the nurse make?

• A. Your weight gain should be less than that for someone without diabetes.
• B. Your weight gain should be the same as that for someone without diabetes.
• C. You should not avoid gaining weight during pregnancy.
• D. You should gain more weight to support the pregnancy.

Correct answer: B

Rationale: During pregnancy, a client with type 2 diabetes mellitus should aim for a weight gain similar to someone without diabetes to ensure a healthy pregnancy. Choice A is incorrect because weight gain should not be less; it should be adequate for pregnancy. Choice C is inaccurate as gaining some weight is essential for a healthy pregnancy. Choice D is incorrect as gaining more weight than necessary can pose risks for both the client and the baby.

4. During an initial assessment of a client, a nurse notices a discrepancy between the client's current IV infusion and the information received during the shift report. Which of the following actions should the nurse take?

• A. Complete an incident report and place it in the client's medical record.
• B. Compare the current infusion with the prescription in the client's medication record.
• C. Contact the charge nurse to see if the prescription was changed.
• D. Submit a written warning for the nurse involved in the incident.

Correct answer: B

Rationale: The correct action for the nurse to take when noticing a discrepancy between the client's current IV infusion and the information received during the shift report is to compare the current infusion with the prescription in the client's medication record. This step is crucial to ensure the accuracy of the prescribed treatment and to prevent any potential harm to the client. Option A is incorrect because completing an incident report should only be done after verifying the discrepancy. Option C is incorrect as contacting the charge nurse should come after confirming the details. Option D is incorrect as submitting a written warning is not appropriate without verifying the information first.

5. A nurse is educating a client on how to use a cane due to left-leg weakness. What should the nurse include in the teaching?

• A. Use the cane on the stronger side
• B. Advance the cane and the weaker leg at the same time
• C. Use the cane on the weaker side
• D. Advance the cane 30 to 45 cm (12-18 in) with each step

Correct answer: A

Rationale: The correct answer is to use the cane on the stronger side. By doing so, the client will have better support and balance. Choice B is incorrect because advancing the cane and the weaker leg at the same time may lead to instability and falls. Choice C is incorrect as using the cane on the weaker side does not provide optimal support. Choice D is incorrect as advancing the cane 30 to 45 cm (12-18 in) with each step is not a standard recommendation for cane use.

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