Nursing Elites

1. A nurse is collecting data from a school-age child who has sustained a skull fracture. Which of the following is a manifestation of increased intracranial pressure?

• A. Nausea
• B. Confusion about own name
• C. Rapid pulse
• D. Vomiting

Correct answer: B

Rationale: Confusion, especially about one's own name, is a sign of increased intracranial pressure and should be addressed. Nausea and vomiting are common symptoms of increased intracranial pressure, but confusion about personal information is a more specific and critical indication that requires immediate attention. Rapid pulse may be a possible response to increased intracranial pressure, but it is not as specific as confusion about own name in this scenario.

2. 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.

3. How should a healthcare professional manage a patient with an indwelling urinary catheter?

• A. Monitor urine output and ensure proper drainage
• B. Administer antibiotics and change the catheter regularly
• C. Monitor for signs of infection and provide catheter care
• D. Provide high-sodium diet and monitor hydration

Correct answer: A

Rationale: Monitoring urine output and ensuring proper catheter drainage are crucial aspects of managing a patient with an indwelling urinary catheter. This helps in assessing the patient's renal function, fluid balance, and the patency of the catheter. Administering antibiotics and changing the catheter regularly (Choice B) may not be necessary unless there is an infection present. While monitoring for signs of infection and providing catheter care (Choice C) are important, the primary focus should be on urine output and drainage. Providing a high-sodium diet and monitoring hydration (Choice D) are not directly related to managing an indwelling urinary catheter.

4. A nurse is caring for a client who has a terminal illness and is approaching death. Which of the following findings should the nurse identify as an indication of impending death?

• A. Hypertension.
• B. Tachycardia.
• C. Cold extremities.
• D. Diaphoresis.

Correct answer: C

Rationale: Cold extremities are a critical sign of impending death as they indicate decreased circulation, leading to poor perfusion to the extremities. This phenomenon occurs as the body redirects blood flow to vital organs, preparing for the end of life. Hypertension and tachycardia are less likely to be seen in the terminal phase and are usually associated with other conditions like shock or sepsis. Diaphoresis, or excessive sweating, may occur in various situations but is not a specific indicator of impending death in this context.

5. When teaching a client with left-leg weakness how to use a cane, which instruction should the nurse include?

• A. Use the cane on the weak side of the body
• B. Advance the cane and the strong leg simultaneously
• C. Maintain two points of support on the floor
• D. Advance the cane 30 to 45 cm (12-18 in) with each step

Correct answer: C

Rationale: The correct instruction for the client with left-leg weakness using a cane is to maintain two points of support on the floor. This ensures stability and balance while walking. Choice A is incorrect because the cane should be used on the strong side of the body to provide additional support. Choice B is incorrect as the cane and the weak leg should move together for support. Choice D is incorrect as advancing the cane too far with each step may compromise balance and stability.

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