Nursing Elites

1. The nurse is assessing an older resident with a history of Benign Prostatic Hypertrophy and identifies a distended bladder. What should the nurse do?

• A. Stand the client to void and run tap water within hearing distance before catheterizing
• B. Straight catheterize and if the residual urine volume is greater than 100 mL, clamp catheter
• C. Catheterize q2h and place in an indwelling catheter at the end of the prescribed 24hr period
• D. Catheterize with an indwelling catheter and if the residual volume is greater than 100 mL, inflate the balloon

Correct answer: D

Rationale: Prompt and appropriate management of urinary retention prevents complications like infection and bladder damage.

2. Which nursing activity is within the scope of practice for the practical nurse?

• A. Complete an admission assessment in the normal newborn nursery
• B. Discontinue a central venous catheter that has become dislodged
• C. Observe a client rotate the subcutaneous site for an insulin pump
• D. Monitor a continuous narcotic epidural for a postoperative client

Correct answer: C

Rationale: The correct answer is C: 'Observe a client rotate the subcutaneous site for an insulin pump.' This activity is within the scope of practice for a practical nurse as it involves observing and ensuring proper technique for using an insulin pump, which aligns with their training and responsibilities. Choices A, B, and D are beyond the typical scope of practice for a practical nurse. Completing an admission assessment for a newborn nursery is usually performed by a registered nurse. Discontinuing a dislodged central venous catheter and monitoring a narcotic epidural require advanced skills and knowledge, usually carried out by registered nurses or advanced practice nurses.

3. What action should the nurse implement in caring for a client following an electroencephalogram (EEG)?

• A. Monitor the client's vital signs every 4 hours
• B. Assess the client's lower extremities for sensation
• C. Instruct the client to maintain bed rest
• D. Wash any paste from the client's hair and scalp

Correct answer: D

Rationale: The correct action the nurse should implement after an EEG is to wash any paste from the client's hair and scalp. This is crucial to prevent irritation and infection at the EEG site. Monitoring vital signs every 4 hours is not specifically indicated after an EEG. Assessing the client's lower extremities for sensation is unrelated to caring for a client post-EEG. While rest may be recommended after the procedure, there is no standard requirement for a specific duration of bed rest.

4. What is the most important action to prevent catheter-associated urinary tract infections (CAUTIs) in a client with an indwelling urinary catheter?

• A. Irrigate the catheter daily.
• B. Change the catheter every 72 hours.
• C. Apply antibiotic ointment at the insertion site.
• D. Ensure the catheter bag is always below bladder level.

Correct answer: D

Rationale: The most crucial action to prevent catheter-associated urinary tract infections (CAUTIs) in a client with an indwelling urinary catheter is to ensure that the catheter bag is always below bladder level. This positioning helps prevent backflow of urine, reducing the risk of CAUTIs. Irrigating the catheter daily (Choice A) is unnecessary and can introduce pathogens. Changing the catheter every 72 hours (Choice B) is not recommended unless clinically indicated to prevent introducing new pathogens. Applying antibiotic ointment at the insertion site (Choice C) is not the most important action to prevent CAUTIs; proper hygiene and maintaining a closed system are more critical.

5. A client with heart failure is prescribed a low-sodium diet. The nurse notices the client's meal tray contains high-sodium foods. What action should the nurse take?

• A. Educate the client about the importance of a low-sodium diet
• B. Replace the meal with a low-sodium option
• C. Report the error to the dietary department
• D. Encourage the client to avoid eating the high-sodium foods

Correct answer: B

Rationale: The correct action for the nurse to take in this situation is to replace the high-sodium meal with a low-sodium option. This immediate intervention ensures that the client adheres to the prescribed low-sodium diet, crucial for managing heart failure and preventing fluid retention. Educating the client (Choice A) about the diet is important but not as urgent as ensuring they receive the correct meal. Reporting the error to the dietary department (Choice C) can be done after addressing the immediate issue. Encouraging the client to avoid high-sodium foods (Choice D) is not as effective as replacing the current meal with a suitable alternative.

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