Nursing Elites

1. 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.

2. A nurse is caring for a client who is in labor and is receiving electronic fetal monitoring. The nurse notes early decelerations. Which of the following should the nurse expect?

• A. Fetal hypoxia
• B. Head compression
• C. Placenta previa
• D. Umbilical cord prolapse

Correct answer: B

Rationale: In the scenario of early decelerations noted during labor with electronic fetal monitoring, the nurse should expect head compression. Early decelerations are a normal response to fetal head compression during contractions and are not indicative of fetal distress. Choice A, fetal hypoxia, is incorrect as early decelerations are not associated with fetal oxygen deprivation. Choices C and D, placenta previa and umbilical cord prolapse, are unrelated to the scenario described and do not cause early decelerations.

3. A client has deep vein thrombosis (DVT). Which of the following interventions should the nurse include in the plan of care?

• A. Apply cold compresses to the affected extremity.
• B. Massage the affected extremity every 2 hours.
• C. Elevate the affected extremity above the level of the heart.
• D. Keep the affected extremity dependent when sitting.

Correct answer: C

Rationale: The correct intervention for a client with deep vein thrombosis (DVT) is to elevate the affected extremity above the level of the heart. This position promotes venous return, reduces swelling, and helps prevent complications such as pulmonary embolism. Applying cold compresses (choice A) can vasoconstrict blood vessels, potentially worsening the condition. Massaging the affected extremity (choice B) can dislodge the clot and lead to serious complications. Keeping the affected extremity dependent when sitting (choice D) can hinder venous return and exacerbate the DVT.

4. A nurse is caring for a client who has cirrhosis and a new prescription for lactulose. The nurse should monitor the client for which of the following therapeutic effects of this medication?

• A. Improved mental status.
• B. Increased urine output.
• C. Decreased serum ammonia.
• D. Decreased bilirubin levels.

Correct answer: C

Rationale: The correct answer is C: Decreased serum ammonia. Lactulose is prescribed to decrease serum ammonia levels in clients with cirrhosis and hepatic encephalopathy. By reducing serum ammonia, lactulose helps improve the mental status of these clients. Therefore, monitoring for decreased serum ammonia is crucial to assess the effectiveness of lactulose therapy. Choice A (Improved mental status) is indirectly related as it is the desired outcome of decreasing ammonia levels. Choices B (Increased urine output) and D (Decreased bilirubin levels) are not directly associated with the therapeutic effects of lactulose in cirrhosis and hepatic encephalopathy.

5. Which electrolyte imbalance should be closely monitored in a patient receiving digoxin?

• A. Monitor potassium levels
• B. Monitor sodium levels
• C. Monitor calcium levels
• D. Monitor glucose levels

Correct answer: A

Rationale: Corrected Rationale: Potassium levels should be monitored closely in a patient receiving digoxin to avoid hypokalemia. Digoxin can increase the risk of developing life-threatening arrhythmias in the presence of low potassium levels. Monitoring sodium, calcium, or glucose levels is not specifically necessary for patients on digoxin, making choices B, C, and D incorrect.

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