Nursing Elites

1. The nurse is caring for a client with an indwelling urinary catheter. Which of the following actions should the nurse prioritize to prevent infection?

• A. Maintain a closed drainage system
• B. Cleanse the catheter insertion site daily
• C. Increase the client's fluid intake
• D. Empty the collection bag every 4 hours

Correct answer: A

Rationale: The correct answer is to maintain a closed drainage system. This action is crucial in preventing infection as it helps prevent bacteria from entering the urinary tract. While cleansing the catheter insertion site and ensuring adequate hydration are important aspects of catheter care, the top priority is maintaining the integrity of the closed system to prevent infection. Emptying the collection bag regularly is also important but not as critical as ensuring a closed drainage system to minimize infection risk.

2. Which strategy should the nurse implement when teaching a client with low literacy about a new diagnosis of hypertension?

• A. Provide a detailed handout with complex terms
• B. Use simple language and visual aids
• C. Encourage the client to research the diagnosis online
• D. Incorporate medical jargon to explain the condition

Correct answer: B

Rationale: The correct strategy for teaching a client with low literacy about a new diagnosis of hypertension is to use simple language and visual aids. This approach helps ensure better understanding of the diagnosis and treatment plan by making the information clear and accessible. Providing a detailed handout with complex terms (Choice A) would not be suitable as it may confuse the client further. Encouraging the client to research the diagnosis online (Choice C) could lead to misinformation and overwhelm the client with information they may not understand. Incorporating medical jargon to explain the condition (Choice D) would not be helpful for a client with low literacy as it may complicate rather than clarify the information.

3. The nurse is performing a functional assessment for a client requiring nursing home care. Which action should the nurse implement?

• A. Question the client about the frequency of falls.
• B. Request the client to lie still during the assessment.
• C. Ask how often episodes of sundowning are experienced.
• D. Assist the client with values clarification about end-of-life care.

Correct answer: A

Rationale: The correct answer is A: Question the client about the frequency of falls. In the elderly population, falls are a significant risk factor that can impact their functional abilities and safety. By assessing the frequency of falls, the nurse can identify potential risks and implement interventions to prevent future falls. Choices B, C, and D are incorrect because they do not directly address the primary focus of a functional assessment for nursing home care, which is to evaluate the client's functional status and identify areas that may require assistance or intervention.

4. A client with a ruptured spleen underwent an emergency splenectomy. Twelve hours later, the client’s urine output is 25 ml/hour. What is the most likely cause?

• A. This is a normal finding after surgery.
• B. Oliguria signals tubular necrosis related to hypoperfusion.
• C. Oliguria signals dehydration and fluid loss.
• D. Urine output of 25 ml/hour is an expected finding after splenectomy.

Correct answer: B

Rationale: Oliguria, or decreased urine output, after surgery can indicate tubular necrosis due to hypoperfusion, which may require intervention to restore renal function. Choice A is incorrect as oliguria is not a normal finding after surgery. Choice C is incorrect because dehydration is less likely in this context compared to tubular necrosis. Choice D is incorrect as a urine output of 25 ml/hour is not expected after splenectomy and should raise concern for renal impairment.

5. A client is diagnosed with tuberculosis and is placed on isoniazid (INH) and rifampin (Rifadin). The nurse should emphasize the importance of

• A. Daily use of a bronchodilator
• B. The importance of taking medication as prescribed
• C. Decreasing salt intake
• D. Avoidance of direct sunlight

Correct answer: B

Rationale: The correct answer is B: The importance of taking medication as prescribed. In the treatment of tuberculosis, adherence to the prescribed medication regimen is crucial to effectively manage the infection and prevent the development of drug resistance. Choices A, C, and D are incorrect because bronchodilators, salt intake, and sunlight exposure are not directly related to the treatment of tuberculosis with isoniazid and rifampin.

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