Nursing Elites

1. After insertion of the indwelling catheter, how should the nurse position the drainage container?

• A. With the drainage tubing taut to maintain maximum suction on the urinary bladder.
• B. Lower than the bladder to maintain a constant downward flow of urine from the bladder.
• C. At the head of the bed for easy and accurate measurement of urine.
• D. Beside the patient in their bed to avoid embarrassment.

Correct answer: B

Rationale: The correct position for the drainage container after inserting an indwelling catheter is to have it placed lower than the bladder. This positioning helps maintain a constant downward flow of urine from the bladder, preventing backflow and ensuring proper drainage. Choice A is incorrect because having the drainage tubing taut does not promote proper urine flow and may cause kinking. Choice C is incorrect as placing the container at the head of the bed does not affect drainage and is not necessary for accurate measurement. Choice D is incorrect as the positioning of the drainage container should prioritize proper drainage and care over potential embarrassment.

2. When measuring vital signs, the healthcare provider observes that a client is using accessory neck muscles during respirations. What follow-up action should the healthcare provider take first?

• A. Determine pulse pressure
• B. Auscultate heart sounds
• C. Measure oxygen saturation
• D. Check for neck vein distention

Correct answer: C

Rationale: Observing a client using accessory neck muscles during respiration indicates respiratory distress. The priority action should be to measure oxygen saturation to assess the adequacy of oxygenation. This intervention provides crucial information about the client's respiratory status and helps guide further assessment and interventions.

3. The client is being taught how to perform active range of motion (ROM) exercises. To exercise the hinge joints, which action should the client be instructed to perform?

• A. Tilt the pelvis forwards and backwards
• B. Bend the arm by flexing the ulnar to the humerus
• C. Turn the head to the right and left
• D. Extend the arm at the side and rotate it in circles

Correct answer: B

Rationale: Hinge joints, like the elbow, primarily allow movement in one direction, in this case, bending the arm. The correct action to exercise hinge joints is to bend the arm by flexing the ulnar to the humerus. This movement specifically targets the hinge joint and promotes its range of motion. Choices A, C, and D involve movements that do not specifically target hinge joints. Tilt the pelvis involves the ball-and-socket joints of the hip, turning the head involves the pivot joint of the neck, and extending the arm and rotating it in circles involve multiple joints including ball-and-socket and pivot joints.

4. UAP has lowered the head of the bed to change the linens for a client who is bedbound with a foley catheter and enteral tube feeds. Which change from the client warrants the most immediate intervention by the nurse?

• A. A feeding is infusing at 40 mL/hr through an enteral feeding tube
• B. The urine meter attached to the urinary drainage bag is completely full
• C. There is a large dependent loop in the client’s urinary drainage tubing
• D. Purulent drainage is present around the insertion site of the feeding tube

Correct answer: D

Rationale: Purulent drainage indicates infection at the insertion site, which requires immediate attention to prevent complications.

5. The patient had a CVA and developed right-sided hemiplegia. Which action is least appropriate for the nurse to take?

• A. Performing ROM exercises during bathing.
• B. Changing the patient's position every two hours.
• C. Suctioning the patient supine and tightly pulling the bed sheets across their feet.
• D. Placing the patient in the prone position for one hour three times a day.

Correct answer: C

Rationale: Suctioning the patient in a supine position and pulling the bed sheets tightly across their feet can lead to foot drop, which is harmful for a patient with right-sided hemiplegia. This action can exacerbate muscle weakness and impair circulation in the affected limb. It is crucial to avoid actions that may compromise the patient's safety and well-being, such as causing foot drop in this scenario.

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