Nursing Elites

1. What intervention should be taken to minimize the risk for injury in a client with dementia?

• A. Use a bed exit alarm system.
• B. Place the client in restraints for safety.
• C. Ensure the client has frequent visitors to reduce isolation.
• D. Keep the client's room dark and quiet at night.

Correct answer: A

Rationale: The correct intervention to minimize the risk for injury in a client with dementia is to use a bed exit alarm system. Bed exit alarms are effective tools to alert healthcare providers when a client attempts to get out of bed, helping prevent falls and injuries. Placing the client in restraints (Choice B) is not the preferred method as it can lead to physical and psychological harm, restrict mobility, and increase agitation. While social interaction is important for clients with dementia, ensuring frequent visitors (Choice C) is not directly related to preventing physical injuries. Keeping the client's room dark and quiet at night (Choice D) may be soothing for some clients but does not directly address the risk for injury associated with dementia.

2. A healthcare provider has inserted an indwelling catheter for a male patient. Where should the healthcare provider tape the catheter to prevent pressure on the client's urethra at the penoscrotal junction?

• A. Lower abdomen
• B. Upper thigh
• C. Penoscrotal junction
• D. Mid-abdomen

Correct answer: A

Rationale: Taping the catheter to the lower abdomen is the correct placement to prevent pressure on the urethra at the penoscrotal junction. Securing the catheter at the lower abdomen helps in reducing discomfort and minimizes the risk of trauma to the urethra. Placing the catheter on the upper thigh or penoscrotal junction can lead to tension on the catheter and potential discomfort for the patient. Taping the catheter to the mid-abdomen is not recommended as it does not provide the necessary support to prevent pressure on the urethra at the penoscrotal junction.

3. The nurse is caring for a client with a nasogastric (NG) tube. Which action should the LPN/LVN take to maintain patency of the tube?

• A. Flush the tube with 30 ml of water before and after medication administration.
• B. Secure the tube to the client's gown.
• C. Check the placement of the tube by auscultation.
• D. Irrigate the tube with normal saline every shift.

Correct answer: A

Rationale: The correct action to maintain patency of a nasogastric (NG) tube is to flush the tube with water before and after medication administration. Flushing helps prevent clogging and ensures that the tube remains clear for proper functioning. Securing the tube to the client's gown (Choice B) is important for stability but does not directly address tube patency. Checking the placement of the tube by auscultation (Choice C) is crucial for verifying correct placement but does not specifically relate to maintaining tube patency. Irrigating the tube with normal saline every shift (Choice D) is not a routine practice for maintaining tube patency and can lead to electrolyte imbalances.

4. During an IV catheter insertion demonstration, which statement by a nurse indicates understanding of the procedure?

• A. “I will thread the needle into the vein at an angle of 10 to 30 degrees with the bevel up.”
• B. “I will insert the needle into the client’s skin at an angle of 10 to 30 degrees with the bevel up.”
• C. “I will apply pressure approximately 1.2 inches below the insertion site before removing the needle.”
• D. “I will select a vein in the antecubital fossa for IV insertion based on its size and easily accessible location.”

Correct answer: B

Rationale: The correct technique for IV catheter insertion involves inserting the needle at a 10 to 30-degree angle with the bevel up. This angle facilitates proper vein puncture, reduces the risk of complications, and minimizes trauma to the vein. Choice A is incorrect because threading the needle into the vein at an angle of 10 to 30 degrees with the bevel up is the correct technique, not threading it all the way into the vein. Choice C is incorrect because applying pressure 1.2 inches below the insertion site before removing the needle is not a standard step in IV catheter insertion. Choice D is incorrect because selecting the antecubital fossa vein solely based on its size and accessibility may not be the most appropriate criterion; vein selection should also consider factors like vein condition and patient comfort.

5. During an abdominal examination, a nurse in a provider’s office determines that a client has abdominal distention. The protrusion is at midline, the skin over the area is taut, and the nurse notes no involvement of the flanks. Which of the following possible causes of distention should the nurse suspect?

• A. Fat
• B. Fluid
• C. Flatus
• D. Hernias

Correct answer: D

Rationale: The correct answer is 'Hernias.' Abdominal distention with a midline protrusion, taut skin, and no involvement of the flanks is characteristic of hernias. Hernias are caused by a weakness in the abdominal wall, allowing organs or tissues to protrude through. Fluid accumulation (ascites) typically presents with a more generalized distention, while fat accumulation may cause more diffuse distension rather than a focal midline protrusion. Flatus, or gas, would not typically present with a visible midline protrusion and taut skin like hernias.

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