Nursing Elites

1. A nurse is preparing to insert an indwelling urinary catheter in a female client. Which action should the nurse take to maintain sterile technique?

• A. Apply sterile gloves before inserting the catheter
• B. Use sterile gloves to insert the catheter
• C. Clean the urinary meatus with an antiseptic solution
• D. Place the drainage bag above the level of the bladder

Correct answer: B

Rationale: Using sterile gloves to insert the catheter is crucial to maintaining sterile technique. Sterile gloves help prevent the introduction of microorganisms during the insertion process. Applying sterile gloves before cleansing the perineal area (Choice A) is important but not specific to maintaining sterility during catheter insertion. Cleaning the urinary meatus with an antiseptic solution (Choice C) is a step in the catheterization process but does not solely ensure sterile technique. Placing the drainage bag above the level of the bladder (Choice D) is incorrect; the bag should be placed below the level of the bladder to facilitate urine drainage.

2. A male client with hypertension tells the nurse that he is going to take ginseng to increase his stamina. What information should the nurse provide this client?

• A. Ginseng can decrease the effectiveness of your blood pressure medication
• B. You will need to stop taking ginseng while on blood pressure medication
• C. It is important to monitor your blood pressure regularly while taking ginseng
• D. Ginseng can increase your blood pressure

Correct answer: D

Rationale: The correct answer is D: "Ginseng can increase blood pressure, which is a concern for clients with hypertension." Choice A is incorrect because ginseng does not typically decrease the effectiveness of blood pressure medication. Choice B is incorrect as stopping ginseng while on blood pressure medication may not be necessary. Choice C is not the most direct concern related to ginseng use in a hypertensive client, making it less relevant than the correct answer.

3. The nurse observes a client in a wheelchair with a vest restraint in place. What nursing intervention is most important for the nurse to implement?

• A. Assess the need for continued restraint
• B. Check the client for urinary incontinence
• C. Determine skin integrity under the vest
• D. Perform range-of-motion exercises on extremities

Correct answer: A

Rationale: The correct answer is to assess the need for continued restraint. This is the most important nursing intervention as it ensures the client's safety and autonomy. Checking for urinary incontinence (Choice B) may be important but is not the priority in this situation. Determining skin integrity under the vest (Choice C) is essential but not as crucial as assessing the need for continued restraint. Performing range-of-motion exercises (Choice D) is important for client mobility but not the priority when a restraint is in place.

4. The nurse offers diet teaching to a female college student who was diagnosed with iron-deficiency anemia following her voluntary adoption of a lacto-vegetarian diet. What nutrients should the nurse suggest this client eat to best meet her nutritional needs while allowing her to adhere to a lacto-vegetarian diet?

• A. Drink whole milk instead of skim milk to enhance the body's production of amino acids
• B. Take vitamin K 10mg PO daily to enhance production of red blood cells
• C. Increase amounts of dark yellow vegetables such as carrots to fortify iron stores
• D. Combine several legumes and grains such as beans and rice to form complete proteins

Correct answer: D

Rationale: Combining legumes and grains ensures the client receives all essential amino acids to form complete proteins, which is crucial in a vegetarian diet. Options A, B, and C are incorrect. Option A is not necessary as there are plant-based sources of essential amino acids in a lacto-vegetarian diet. Option B suggests vitamin K, which is not directly related to enhancing red blood cell production. Option C mentions increasing dark yellow vegetables, which are sources of non-heme iron, but combining legumes and grains is more effective in addressing the protein needs of a lacto-vegetarian.

5. A 7-year-old with cystic fibrosis (CF) has received instructions about home care. Which statement made by the child's mother indicates that further teaching is needed?

• A. My child should not have a cough at all times
• B. He needs to take pancreatic enzymes with meals and snacks
• C. He needs to use a bronchodilator every day
• D. His dietary intake needs to be high in protein and calories

Correct answer: A

Rationale: The correct answer is A. A cough at all times is not normal in a child with cystic fibrosis (CF) and indicates the need for further teaching on CF management. Choices B, C, and D are correct statements in managing CF: taking pancreatic enzymes with meals and snacks, using a bronchodilator daily, and maintaining a high-protein and high-calorie dietary intake are all appropriate for a child with CF.

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