Nursing Elites

1. A nurse is preparing to insert an indwelling urinary catheter for a male client. Which of the following actions should the nurse take?

• A. Insert the catheter until urine flows, then advance 2.5 to 5 cm (1 to 2 in) further.
• B. Advance the catheter 7.5 to 10 cm (3 to 4 in) after urine begins to flow.
• C. Advance the catheter 17 to 22.5 cm (7 to 9 in) after urine begins to flow.
• D. Advance the catheter 5 to 7.5 cm (2 to 3 in) after urine begins to flow.

Correct answer: C

Rationale: When inserting an indwelling urinary catheter for a male client, it is crucial to advance the catheter 17 to 22.5 cm after urine begins to flow. This helps ensure proper placement in the male urethra, which is longer compared to females. Choice A is incorrect as advancing only 2.5 to 5 cm would not reach the correct placement in male clients. Choice B is incorrect as advancing 7.5 to 10 cm is insufficient to reach the appropriate location in male clients. Choice D is also incorrect as advancing 5 to 7.5 cm would likely not reach the desired placement in male clients.

2. A client has a new prescription for enoxaparin. Which of the following instructions should the nurse include?

• A. Take this medication with food to reduce stomach upset.
• B. Inject this medication into the muscle.
• C. Massage the injection site after administering the medication.
• D. Inject this medication into the abdomen.

Correct answer: D

Rationale: The correct answer is D because enoxaparin should be injected into the abdomen to ensure proper absorption. Choice A is incorrect as enoxaparin should not be taken with food. Choice B is incorrect as enoxaparin should be injected subcutaneously, not into the muscle. Choice C is incorrect as massaging the injection site after administering enoxaparin is not recommended.

3. How should a healthcare professional manage a patient with fluid overload in heart failure?

• A. Monitor daily weight
• B. Check for edema
• C. Monitor intake and output
• D. Administer diuretics

Correct answer: A

Rationale: Monitoring daily weight is crucial in managing a patient with fluid overload in heart failure. Weight fluctuations can indicate fluid retention or loss, guiding healthcare professionals in adjusting treatment. While checking for edema (Choice B) and monitoring intake and output (Choice C) are important aspects of patient care, they are not as direct in assessing fluid overload as daily weight monitoring. Administering diuretics (Choice D) is a treatment option based on the assessment of fluid overload, making it a secondary intervention compared to monitoring weight.

4. A nurse is caring for a newborn who is 1-day-old and receiving phototherapy for jaundice. Which of the following actions should the nurse take?

• A. Feed the infant 30 ml (1 oz) of glucose water every 2 hours.
• B. Keep the infant's head covered with a cap.
• C. Ensure that the newborn wears a diaper.
• D. Apply lotion to the newborn every 4 hours.

Correct answer: C

Rationale: The correct action for the nurse to take is to ensure that the newborn wears a diaper. This is important to prevent skin irritation during phototherapy. Choice A is incorrect as newborns should be breastfed or formula-fed, not given glucose water. Choice B is unnecessary and may interfere with the effectiveness of phototherapy. Choice D is inappropriate as lotions can interfere with the phototherapy and increase the risk of skin damage.

5. A healthcare provider is preparing to administer an intramuscular injection to a client. Which of the following actions should the provider take?

• A. Insert the needle at a 90-degree angle
• B. Insert the needle at a 45-degree angle
• C. Inject the medication slowly after aspiration
• D. Massage the site after injection

Correct answer: A

Rationale: Correct answer: When administering an intramuscular injection, the needle should be inserted at a 90-degree angle to ensure proper delivery of the medication into the muscle tissue. Option B is incorrect because a 45-degree angle is typically used for subcutaneous injections, not intramuscular. Option C is incorrect as aspiration is not recommended for intramuscular injections. Option D is incorrect as massaging the site after an intramuscular injection can cause tissue damage or interfere with the absorption of the medication.

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