Nursing Elites

1. A nurse in a pediatric unit is preparing to insert an IV catheter for a 7-year-old. Which of the following actions should the nurse take?

• A. Allow the child to handle the IV supplies to become familiar with them.
• B. Tell the child they will feel discomfort during the catheter insertion.
• C. Use a mummy restraint to hold the child during the catheter insertion.
• D. Require the parents to leave the room during the procedure.

Correct answer: B

Rationale: The correct answer is B because informing the child that they will feel discomfort during catheter insertion is crucial to prepare them for the procedure. Choice A is incorrect as children should not handle medical supplies. Choice C is inappropriate as using a restraint can cause anxiety and fear in the child. Choice D is not necessary as having parents present can provide comfort and support to the child during the procedure.

2. What is the most appropriate action when a patient is experiencing severe dehydration?

• A. Administer IV fluids
• B. Encourage oral fluids
• C. Monitor electrolytes
• D. Perform a neurological exam

Correct answer: A

Rationale: The most appropriate action when a patient is experiencing severe dehydration is to administer IV fluids. This intervention is crucial in rapidly correcting dehydration and restoring fluid balance. Encouraging oral fluids may not be sufficient in cases of severe dehydration where intravenous rehydration is needed. Monitoring electrolytes is important but administering fluids takes precedence in severe dehydration. Performing a neurological exam is not the primary intervention for severe dehydration.

3. A client with a new diagnosis of hypertension is being taught by a nurse. Which of the following statements by the client indicates an understanding of the teaching?

• A. I will decrease my potassium intake while taking this medication.
• B. I will need to take medication for the rest of my life.
• C. I will avoid using salt substitutes.
• D. I will avoid drinking grapefruit juice.

Correct answer: C

Rationale: The correct answer is C. Clients with hypertension should avoid salt substitutes because they often contain potassium, which can raise potassium levels. Choice A is incorrect as decreasing potassium intake is not necessary unless advised by a healthcare provider. Choice B is incorrect as not all clients with hypertension need to take medication for life. Choice D is incorrect as grapefruit juice does not significantly impact hypertension management.

4. A client with cancer is about to receive low-dose brachytherapy via a vaginal implant. What intervention should be included in the care plan?

• A. Remove vaginal packing.
• B. Insert an indwelling urinary catheter.
• C. Ambulate the client four times daily.
• D. Keep the client NPO until therapy is complete.

Correct answer: B

Rationale: The correct intervention that should be included in the care plan for a client about to receive low-dose brachytherapy via a vaginal implant is to insert an indwelling urinary catheter. This is crucial to prevent bladder distention during brachytherapy, ensuring the treatment's effectiveness and the client's comfort. Removing vaginal packing (Choice A) may not be necessary or appropriate in this situation. Ambulating the client four times daily (Choice C) is a good nursing intervention for general patient care but is not specifically related to brachytherapy via a vaginal implant. Keeping the client NPO until therapy is complete (Choice D) is not necessary unless specifically indicated due to the treatment's nature or the client's condition.

5. A nurse is preparing to insert an indwelling urinary catheter for a client. Which of the following actions should the nurse take?

• A. Insert the catheter 7.5 cm (3 in) into the urethra.
• B. Insert the catheter until urine flow is established.
• C. Cleanse the catheter with sterile water before insertion.
• D. Insert the catheter 5 cm (2 in) into the urethra.

Correct answer: B

Rationale: The correct action for the nurse is to insert the catheter until urine flow is established. This helps ensure proper placement and reduces the risk of trauma. Choice A (7.5 cm) and Choice D (5 cm) provide specific measurements that may not be appropriate for all individuals as catheter insertion depth can vary. Choice C is incorrect as catheters should be cleansed with an appropriate solution such as sterile saline, not sterile water.

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