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. What is the priority nursing action during the immediate postoperative period for a client who just underwent a coronary artery bypass graft?

• A. Monitor for signs of infection
• B. Ensure the client is pain-free
• C. Assess for bleeding and arrhythmias
• D. Maintain a patent airway

Correct answer: D

Rationale: Maintaining a patent airway is the priority nursing action during the immediate postoperative period for a client who just underwent a coronary artery bypass graft. This is crucial to ensure adequate oxygenation, especially in the early recovery phase. Monitoring for signs of infection, ensuring the client is pain-free, and assessing for bleeding and arrhythmias are important aspects of postoperative care but maintaining a clear airway takes precedence in this scenario to prevent hypoxia and respiratory compromise. In the immediate postoperative period, maintaining a patent airway is essential to prevent complications such as airway obstruction, hypoxia, and respiratory distress, which are critical in ensuring the client's safety and recovery.

3. A client with a diagnosis of chronic heart failure is receiving digoxin. What is the most important assessment before administering this medication?

• A. Check blood pressure.
• B. Assess heart rate.
• C. Monitor respiratory rate.
• D. Measure oxygen saturation.

Correct answer: B

Rationale: The correct answer is to assess the heart rate. Before administering digoxin, it is essential to evaluate the heart rate as digoxin can cause bradycardia. While checking blood pressure, monitoring respiratory rate, and measuring oxygen saturation are important assessments in the care of a client with chronic heart failure, assessing the heart rate is particularly critical due to the medication's potential impact on heart rhythm.

4. A client complains of pain at the IV site. Upon assessment, the nurse notes the site is warm, red, and swollen. What is the most likely cause of these findings?

• A. Phlebitis
• B. Infiltration
• C. Allergic reaction
• D. Fluid overload

Correct answer: A

Rationale: The correct answer is A, Phlebitis. Phlebitis is the inflammation of a vein, often caused by irritation from an IV catheter, resulting in warmth, redness, and swelling at the site. Infiltration (choice B) refers to the leaking of IV fluids into the surrounding tissues, causing swelling and pallor, not redness and warmth like in the scenario described. An allergic reaction (choice C) would present with itching, hives, or anaphylaxis, rather than localized warmth, redness, and swelling. Fluid overload (choice D) typically manifests as generalized edema, shortness of breath, and weight gain, not localized symptoms at the IV site.

5. During a community health fair, a nurse is providing education on the effects of smoking. What is the most important information to include?

• A. Smoking can lead to cosmetic issues like tooth staining.
• B. Smoking is a leading cause of preventable death worldwide.
• C. Smoking temporarily elevates mood and alertness.
• D. Smoking is an expensive habit.

Correct answer: B

Rationale: The correct answer is B: 'Smoking is a leading cause of preventable death worldwide.' This information is crucial as it highlights the severe health risks associated with smoking, emphasizing the importance of cessation for overall health. Choice A is incorrect because cosmetic issues like tooth staining are not as significant as the life-threatening consequences of smoking. Choice C is incorrect because although smoking may temporarily elevate mood and alertness due to nicotine, this does not outweigh the serious health implications. Choice D is incorrect as while smoking is indeed an expensive habit, the focus should be on the health-related consequences to stress the urgency of quitting.

Similar Questions