Nursing Elites

1. When inserting an indwelling urinary catheter in a female client and urine flows into the tubing, what is the next action?

• A. Document the color and clarity of the urine
• B. Insert the catheter an additional inch
• C. Ask the client to breathe deeply and slowly exhale
• D. Inflate the balloon with 5 mL of sterile water

Correct answer: D

Rationale: When urine flows into the tubing during the insertion of an indwelling urinary catheter, it confirms proper catheter placement. The next step should be to inflate the balloon with the specified amount of sterile water to secure the catheter in place. Documenting the color and clarity of the urine (choice A) is important for assessment but not the immediate next action. Inserting the catheter further (choice B) without securing it could cause harm. Asking the client to breathe deeply (choice C) is not relevant to this situation.

2. The nurse is assessing a client with hyperkalemia. Which finding is consistent with this electrolyte imbalance?

• A. Muscle weakness
• B. Decreased deep tendon reflexes
• C. Constipation
• D. Hypotension

Correct answer: A

Rationale: Muscle weakness is a common finding in clients with hyperkalemia. Hyperkalemia can lead to muscle weakness due to the effect of high potassium levels on muscle function. Decreased deep tendon reflexes (Choice B) are not typically associated with hyperkalemia; instead, hyperreflexia or increased reflexes may be observed. Constipation (Choice C) is not a common symptom of hyperkalemia. Hypotension (Choice D) is also not a typical finding in hyperkalemia; instead, hypertension or normal blood pressure may be present.

3. The nurse is monitoring a client's intravenous infusion and observes that the venipuncture site is cool to the touch, swollen, and the infusion rate is slower than the prescribed rate. What is the most likely cause of this finding?

• A. The solution's rate is too rapid
• B. The client has phlebitis
• C. The infusion site is infected
• D. The infusion is infiltrated

Correct answer: D

Rationale: The correct answer is D. An infiltrated IV occurs when fluid leaks into the surrounding tissue, causing coolness, swelling, and a slow infusion rate. Choice A is incorrect because a rapid solution rate does not typically cause these specific symptoms. Choice B, phlebitis, presents with redness, warmth, and tenderness along the vein, not coolness. Choice C, infection, usually manifests with redness, warmth, and possibly purulent drainage, not coolness and swelling.

4. During a home visit, a nurse finds that an elderly client is having trouble remembering to take their medications. What is the best intervention?

• A. Set up a pill organizer
• B. Involve family members in care
• C. Arrange for a home health aide
• D. Implement all of the above

Correct answer: D

Rationale: The best intervention when an elderly client is having trouble remembering to take their medications is to implement all of the above options. Setting up a pill organizer helps in organizing and remembering medication schedules. Involving family members in care ensures additional support and reminders. Arranging for a home health aide can provide direct assistance and supervision. Implementing all these strategies together can significantly improve medication adherence, especially in clients with memory issues. Each option plays a crucial role in addressing different aspects of the problem, making 'Implement all of the above' the most comprehensive and effective choice.

5. The nurse is teaching a client about the administration of a subcutaneous injection. Which site is most appropriate for this type of injection?

• A. Deltoid muscle
• B. Dorsogluteal muscle
• C. Ventrogluteal muscle
• D. Abdomen

Correct answer: D

Rationale: The abdomen is a common site for subcutaneous injections due to its accessibility and ample subcutaneous tissue. Subcutaneous injections are typically given in areas with a layer of fat between the skin and muscle, such as the abdomen, to allow for slow and consistent absorption of the medication. The deltoid muscle is more appropriate for intramuscular injections, not subcutaneous. The dorsogluteal muscle and ventrogluteal muscle are also more suited for intramuscular injections, not subcutaneous.

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