Nursing Elites

1. The nurse is caring for a client who has just returned from surgery with a urinary catheter in place. What is the most important action to prevent catheter-associated urinary tract infections (CAUTIs)?

• A. Irrigate the catheter daily
• B. Ensure the catheter bag is always below bladder level
• C. Change the catheter every 48 hours
• D. Administer prophylactic antibiotics

Correct answer: B

Rationale: The correct answer is to ensure the catheter bag is always below bladder level. This positioning helps prevent backflow of urine, reducing the risk of CAUTIs. Choice A, irrigating the catheter daily, is not recommended as it can introduce pathogens into the bladder. Changing the catheter too frequently (Choice C) can increase the risk of introducing pathogens. Administering prophylactic antibiotics (Choice D) is not the primary intervention for preventing CAUTIs and can lead to antibiotic resistance.

2. The healthcare provider is preparing to administer an IM injection to an adult client. Which site is the preferred location for this injection?

• A. Deltoid muscle
• B. Vastus lateralis muscle
• C. Ventrogluteal muscle
• D. Dorsogluteal muscle

Correct answer: C

Rationale: The ventrogluteal site is the preferred site for IM injections in adults due to its muscle mass and low risk of nerve injury. The deltoid muscle, although commonly used for vaccines in adults due to easy accessibility, has a smaller muscle mass making it less ideal for IM injections. The vastus lateralis muscle is typically used in infants and young children, not in adults. The dorsogluteal site has a higher risk of injury to the sciatic nerve and is no longer recommended for IM injections in any age group.

3. A client with a diagnosis of osteoporosis is prescribed alendronate (Fosamax). What is the most important instruction the nurse should provide?

• A. Take the medication in the morning on an empty stomach.
• B. Take the medication at bedtime.
• C. Remain upright for at least 30 minutes after taking the medication.
• D. Take the medication with a full glass of water.

Correct answer: D

Rationale: The most important instruction the nurse should provide to a client prescribed alendronate (Fosamax) for osteoporosis is to take the medication with a full glass of water. This is crucial to help prevent esophageal irritation. Option A is correct as alendronate should be taken in the morning on an empty stomach. Option C is incorrect because the client should remain upright for at least 30 minutes after taking the medication, not lie down. Option B is incorrect and a duplicate of Option A.

4. A client is receiving a blood transfusion and reports chills and back pain. What is the nurse's priority action?

• A. Continue the transfusion at a slower rate
• B. Administer an antipyretic
• C. Stop the transfusion immediately
• D. Notify the healthcare provider

Correct answer: C

Rationale: When a client receiving a blood transfusion reports chills and back pain, it indicates a possible transfusion reaction. The nurse's priority action is to stop the transfusion immediately. Continuing the transfusion at a slower rate (Choice A) can exacerbate the reaction. Administering an antipyretic (Choice B) may help with fever but does not address the underlying issue of a transfusion reaction. Notifying the healthcare provider (Choice D) is important but should not delay the immediate action of stopping the transfusion to ensure the client's safety.

5. A client with a diagnosis of chronic kidney disease (CKD) is receiving epoetin alfa (Epogen). What is the primary goal of this medication?

• A. To reduce the risk of bleeding.
• B. To lower blood pressure.
• C. To stimulate red blood cell production.
• D. To increase appetite.

Correct answer: C

Rationale: The correct answer is C: 'To stimulate red blood cell production.' Epoetin alfa, such as Epogen, is used to treat anemia by stimulating red blood cell production in clients with chronic kidney disease. This medication helps increase hemoglobin levels and reduce the need for blood transfusions. Option A, 'To reduce the risk of bleeding,' is incorrect as epoetin alfa does not directly impact bleeding risk. Option B, 'To lower blood pressure,' is incorrect as epoetin alfa is not indicated for blood pressure management. Option D, 'To increase appetite,' is also incorrect as the primary goal of epoetin alfa is related to improving anemia by boosting red blood cell production.

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