Nursing Elites

1. A nurse is assessing a client who is postoperative following a transurethral resection of the prostate (TURP) and notices clots in the client's urinary catheter and decreased urinary output. Which of the following actions should the nurse take?

• A. Administer an antispasmodic
• B. Irrigate the catheter with 0.9% sodium chloride irrigation
• C. Apply gentle manual pressure to the bladder
• D. Clamp the catheter tubing

Correct answer: B

Rationale: In this situation, the nurse should irrigate the catheter with 0.9% sodium chloride irrigation. This action helps clear the clots in the catheter and restore proper urine flow after a TURP. Administering an antispasmodic (Choice A) is not the appropriate action for clots in the catheter and decreased urinary output. Applying gentle manual pressure to the bladder (Choice C) or clamping the catheter tubing (Choice D) could potentially worsen the situation by causing bladder distention or preventing urine drainage.

2. How can dehydration be assessed in an elderly patient?

• A. Checking skin turgor on the forearm
• B. Assessing for dry mucous membranes
• C. Checking for orthostatic hypotension
• D. Measuring daily weights

Correct answer: A

Rationale: Assessing skin turgor by gently pinching the skin on the forearm is a reliable method to check for dehydration in elderly patients. When the skin is slow to return to its original position, it indicates dehydration. While assessing for dry mucous membranes is also important, checking skin turgor is a more direct method for dehydration assessment. Checking for orthostatic hypotension is more related to circulation status than dehydration. Measuring daily weights is helpful to monitor fluid balance but may not be as immediate or direct in detecting dehydration in elderly patients.

3. A client who reports insomnia is being taught by a nurse about promoting rest and sleep. Which statement should indicate to the nurse that the client understands the instructions?

• A. I will walk briskly for 30 minutes before bedtime
• B. I will have a cup of hot cocoa immediately before bedtime
• C. I will no longer have a glass of wine before bedtime
• D. I will do my muscle relaxation techniques each afternoon

Correct answer: C

Rationale: The correct answer is C because avoiding alcohol before bedtime can help promote better sleep. Choice A is incorrect as vigorous exercise close to bedtime can actually hinder sleep. Choice B is also incorrect as consuming beverages with caffeine or sugar close to bedtime can disrupt sleep. Choice D, while a good practice, does not directly address the issue of avoiding alcohol before bedtime to improve sleep quality.

4. A nurse is preparing to administer enoxaparin subcutaneously to a client. Which of the following actions should the nurse take?

• A. Inject at a 90-degree angle
• B. Inject at a 45-degree angle
• C. Massage the injection site after administering
• D. Use a longer needle

Correct answer: B

Rationale: The correct answer is to inject enoxaparin subcutaneously at a 45-degree angle. This angle helps ensure proper delivery of the medication into the subcutaneous tissue. Option A (Inject at a 90-degree angle) is incorrect because subcutaneous injections are usually given at a shallower angle. Option C (Massage the injection site after administering) is incorrect as massaging the site can cause bruising and should generally be avoided. Option D (Use a longer needle) is incorrect as using a longer needle is unnecessary and may increase the risk of injecting the medication too deeply.

5. A nurse is teaching an older adult client who reports constipation. Which of the following instructions should the nurse include in the teaching?

• A. Increase dietary intake of raw vegetables
• B. Limit activity
• C. Drink four to five glasses of water daily
• D. Bear down hard when defecating

Correct answer: C

Rationale: The correct instruction the nurse should include is to advise the client to drink four to five glasses of water daily. Increasing water intake helps alleviate constipation by softening stool and increasing bowel movements. Choice A, increasing dietary intake of raw vegetables, can be helpful in preventing constipation but may not be sufficient as the sole intervention for someone already experiencing constipation. Choice B, limiting activity, can worsen constipation as physical activity helps stimulate bowel movements. Choice D, bearing down hard when defecating, can lead to other issues like hemorrhoids and should be avoided.

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