Nursing Elites

1. A client has an indwelling urinary catheter. Which of the following actions should the nurse take to prevent infection?

• A. Ensure the catheter tubing is free of kinks.
• B. Clean the perineal area with antiseptic solution daily.
• C. Irrigate the catheter with normal saline every shift.
• D. Secure the catheter to the client's leg.

Correct answer: B

Rationale: Cleaning the perineal area with antiseptic solution daily is essential to prevent infection when caring for a client with an indwelling urinary catheter. This practice helps reduce the risk of introducing pathogens into the urinary tract. Ensuring the catheter tubing is free of kinks (Choice A) is important for maintaining proper urine flow but is not directly related to preventing infection. Irrigating the catheter with normal saline every shift (Choice C) is not a routine practice and can increase the risk of introducing pathogens. Securing the catheter to the client's leg (Choice D) is important for stability but does not directly prevent infection.

2. The LPN is instructing a client with high cholesterol about diet and lifestyle modifications. What comment from the client indicates that the teaching has been effective?

• A. If I exercise at least twice weekly for one hour, I will lower my cholesterol.
• B. I need to avoid eating proteins, including red meat.
• C. I will limit my intake of beef to 4 ounces per week.
• D. My blood level of low-density lipoproteins needs to increase.

Correct answer: C

Rationale: The correct answer is C. Limiting intake of beef to 4 ounces per week is an effective dietary modification to manage high cholesterol. Choice A is incorrect because the frequency and duration of exercise alone may not be sufficient to lower cholesterol significantly. Choice B is incorrect as proteins, including lean sources like poultry and fish, can be a part of a healthy diet. Choice D is incorrect as low-density lipoproteins, known as bad cholesterol, should be decreased, not increased, for heart health.

3. A client has left lower atelectasis. In which of the following positions should the nurse place the client for postural drainage?

• A. Supine and low Fowler's position
• B. Right lateral in Trendelenburg position
• C. Side lying with the right side of the chest elevated
• D. Prone with pillows under the extremities

Correct answer: B

Rationale: Postural drainage is a technique used to help remove secretions from specific lung segments. For left lower atelectasis, placing the client in the right lateral Trendelenburg position is most effective. This position helps target the affected area, using gravity to assist in drainage. Placing the client in a supine or low Fowler's position (Choice A) may not effectively target the affected area. Side lying with the right side of the chest elevated (Choice C) would not utilize gravity for optimal drainage. Placing the client prone with pillows under the extremities (Choice D) is not ideal for postural drainage of the left lower lobe.

4. The patient has undergone surgery for a broken leg and has a cast in place. What should the nurse do to prevent skin impairment?

• A. Assess surfaces exposed to the edges of the cast for pressure areas.
• B. Keep the patient's blood pressure low to prevent overperfusion of tissue.
• C. Allow turning in bed to prevent complications.
• D. Encourage the patient's dietary intake to maintain hydration.

Correct answer: A

Rationale: To prevent skin impairment in a patient with a cast, the nurse should assess surfaces exposed to the edges of the cast for pressure areas. This is important to prevent pressure ulcers or skin breakdown. Keeping the patient's blood pressure low (Choice B) is not directly related to preventing skin impairment in this scenario. Allowing turning in bed (Choice C) is essential for preventing complications like pressure ulcers and is not contraindicated. Encouraging the patient's dietary intake (Choice D) to maintain hydration is not directly related to preventing skin impairment associated with a cast.

5. A nurse on a medical-surgical unit is caring for a client. Which of the following actions should the nurse take first when using the nursing process?

• A. Obtain client information
• B. Develop a plan of care
• C. Implement nursing interventions
• D. Evaluate the client's response to treatment

Correct answer: A

Rationale: The correct answer is A: Obtain client information. The first step in the nursing process is assessment, which involves gathering data about the client's condition, needs, and preferences. This information forms the foundation for developing a comprehensive plan of care. Developing a plan of care (Choice B) comes after assessment to address the identified needs. Implementing nursing interventions (Choice C) follows the development of the plan of care. Evaluating the client's response to treatment (Choice D) occurs after implementing the interventions to determine the effectiveness of the care provided. Therefore, the initial and priority step is to obtain client information through assessment.

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