Nursing Elites

1. During an admission interview, a nurse is assessing a client's personal identity. Which of the following questions should the nurse ask?

• A. What is your marital status?
• B. How would you describe yourself?
• C. Are you employed?
• D. Do you have any children?

Correct answer: B

Rationale: When assessing personal identity, it is important to ask questions that prompt clients to describe themselves. Question B, 'How would you describe yourself?' is the most appropriate as it allows the client to share their own perceptions and characteristics, aiding in understanding their personal identity. Choices A, C, and D are more focused on specific personal details such as marital status, employment status, and parental status, which do not directly contribute to understanding personal identity.

2. When teaching a client about the proper use of a cane, which of the following instructions should be included?

• A. Hold the cane on the weaker side.
• B. Move the cane forward first.
• C. Keep the cane 12 inches away from the body.
• D. Use the cane for support only when climbing stairs.

Correct answer: B

Rationale: When using a cane, it is crucial to move the cane forward first to provide support and enhance balance. Advancing the cane before the weaker or stronger leg helps widen the base of support, thereby improving stability during ambulation. Keeping the cane too far or too close to the body can affect its supportive function. Moreover, utilizing the cane solely for stair climbing limits its overall utility in maintaining balance and stability during regular walking.

3. A healthcare professional is preparing to insert an IV catheter for an older adult client. Which of the following actions should the professional take?

• A. Shave the hair at the insertion site.
• B. Insert the catheter at a 45-degree angle.
• C. Place the client’s arm in a dependent position.
• D. Use a tourniquet to dilate the veins.

Correct answer: C

Rationale: Placing the client’s arm in a dependent position is the correct action when preparing to insert an IV catheter in an older adult client. This position helps dilate the veins naturally by using gravity, making it easier to locate and access suitable veins for the IV catheter insertion. By positioning the arm in a dependent position, the healthcare professional can take advantage of gravity to increase venous distention, aiding in successful IV catheter insertion.

4. Which of the following statements indicates the client understands the colostomy care instructions?

• A. I will change the colostomy bag once a week.
• B. I will avoid eating high-fiber foods.
• C. I will clean around the stoma with mild soap and water.
• D. I will apply lotion to the skin around the stoma.

Correct answer: C

Rationale: The correct answer is C. Cleaning around the stoma with mild soap and water is crucial for colostomy care as it helps prevent infection and skin irritation. Changing the colostomy bag frequency, dietary modifications, or applying lotion are not primary aspects of stoma care. Proper cleaning around the stoma helps maintain hygiene and prevents complications, making it a key component of caring for a colostomy.

5. A client has a prescription for a 24-hour urine collection. Which of the following actions should be taken by the healthcare provider?

• A. Discard the first voiding.
• B. Keep the urine at room temperature.
• C. Collect the first voiding.
• D. Keep the urine in a sterile container.

Correct answer: A

Rationale: Discarding the first voiding is necessary when initiating a 24-hour urine collection to ensure that the collection starts with an empty bladder. This step helps in obtaining an accurate measurement of substances excreted over the 24-hour period without any carryover from the previous voids. Keeping the urine at room temperature or in a sterile container is not specific to the initiation of the collection. Therefore, the correct action is to discard the first voiding. Choice B is incorrect because keeping urine at room temperature is important for some tests, but it is not specific to the initiation of a 24-hour urine collection. Choice C is incorrect because collecting the first voiding would lead to inaccurate results as the bladder is not empty at the start. Choice D is incorrect because while keeping urine in a sterile container is generally a good practice, it is not a specific step for initiating a 24-hour urine collection.

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