Nursing Elites

1. A nurse is caring for a client who is postoperative following abdominal surgery. What behavior should the nurse identify as increasing the client's risk for constipation?

• A. Increased physical activity
• B. Frequent urge suppression
• C. Adequate sleep
• D. Increased fluid intake

Correct answer: B

Rationale: Frequent urge suppression can lead to constipation, especially postoperatively. Suppressing the urge to defecate can disrupt the normal bowel movement pattern and lead to constipation. Choices A, C, and D are behaviors that generally help prevent constipation rather than increase the risk. Increased physical activity, adequate sleep, and increased fluid intake promote bowel regularity and reduce the risk of constipation.

2. A nurse is providing discharge teaching to a client with a new diagnosis of hypertension. What lifestyle modification should the nurse emphasize?

• A. Decrease potassium intake
• B. Increase fluid intake to 2 liters per day
• C. Avoid foods high in calcium
• D. Increase sodium intake

Correct answer: B

Rationale: The correct lifestyle modification that the nurse should emphasize for a client with hypertension is to increase fluid intake to 2 liters per day. Proper hydration helps manage hypertension by supporting kidney function in regulating blood pressure and by diluting sodium levels in the body. Decreasing potassium intake (Choice A) is not recommended, as potassium-rich foods like fruits and vegetables are beneficial for blood pressure control. Avoiding foods high in calcium (Choice C) is not directly related to managing hypertension, and increasing sodium intake (Choice D) is contraindicated as excess sodium can elevate blood pressure.

3. A nurse is caring for a client who reports pain at the site of an indwelling urinary catheter. What is the nurse's first action?

• A. Irrigate the catheter with normal saline
• B. Notify the provider
• C. Apply a warm compress to the site
• D. Administer pain medication

Correct answer: B

Rationale: The correct first action for the nurse to take when a client reports pain at the site of an indwelling urinary catheter is to notify the provider. Pain at the catheter site may indicate complications such as infection or blockage, which require further assessment and intervention by the healthcare provider. Irrigating the catheter, applying a warm compress, or administering pain medication should not be done without provider evaluation as they do not address the underlying cause of the pain and may potentially worsen the situation.

4. A client is reviewing a medical record for advance directives. Which client statement indicates an understanding of the teaching?

• A. I don't need a living will because my family will make decisions.
• B. My living will takes effect only if I lose consciousness.
• C. My family will decide when to follow my living will.
• D. I can change my living will at any time.

Correct answer: D

Rationale: The correct answer is D because clients can change their living will at any time as long as they are mentally competent. Choice A is incorrect because relying solely on family to make decisions may not align with the client's wishes. Choice B is incorrect because a living will can address various situations, not just loss of consciousness. Choice C is incorrect because the client should be the primary decision-maker regarding their living will, not the family.

5. A nurse is caring for a client who has experienced a seizure. What should the nurse do immediately after the seizure?

• A. Administer oxygen
• B. Document the seizure activity
• C. Turn the client on their side
• D. Reassure the client

Correct answer: C

Rationale: After a client experiences a seizure, the nurse should immediately turn the client on their side. This action helps maintain an open airway and prevents aspiration, as it allows any secretions or vomitus to drain from the mouth. Administering oxygen can be necessary if the client is hypoxic, but turning the client on their side takes precedence to prevent complications. While documenting the seizure activity is important for the client's medical record, ensuring the client's immediate safety by positioning them correctly is the priority. Reassuring the client should follow after ensuring their physical safety.

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