Nursing Elites

1. What action should the nurse take for a client struggling to void after having an indwelling catheter removed?

• A. Assess for bladder distention after 2 hours
• B. Encourage the client to try urinating in a sitting position
• C. Pour warm water over the client's perineum
• D. Restrict the client's fluid intake

Correct answer: C

Rationale: The correct action for the nurse to take is to pour warm water over the client's perineum. This intervention helps stimulate urination after catheter removal by providing warmth and promoting relaxation of the muscles. Assessing for bladder distention after 2 hours (Choice A) is not the initial intervention to facilitate voiding. Encouraging the client to try urinating in a sitting position (Choice B) may be uncomfortable if the client is struggling to void. Restricting the client's fluid intake (Choice D) is not appropriate as it can further exacerbate the issue by concentrating the urine.

2. What are the risk factors for deep vein thrombosis (DVT) and how can it be prevented?

• A. Immobility and oral contraceptive use
• B. Pregnancy and smoking
• C. Obesity and varicose veins
• D. Hypertension and high cholesterol

Correct answer: A

Rationale: The correct answer is A: Immobility and oral contraceptive use. Immobility and oral contraceptive use are significant risk factors for deep vein thrombosis (DVT). Immobility leads to blood stasis, increasing the risk of clot formation, while oral contraceptive use can promote hypercoagulability. Prevention strategies for DVT include promoting mobility to enhance blood circulation and using anticoagulants to prevent clot formation. Choices B, C, and D are incorrect. While pregnancy and smoking can increase the risk of DVT, they are not the specific factors mentioned in the question. Similarly, obesity and varicose veins, as well as hypertension and high cholesterol, are not the primary risk factors associated with DVT.

3. A nurse is caring for a client who has hypokalemia. Which of the following clinical findings should the nurse expect?

• A. Hyperactive reflexes.
• B. Strong, bounding pulse.
• C. Decreased bowel sounds.
• D. Increased deep tendon reflexes.

Correct answer: C

Rationale: The correct answer is C: Decreased bowel sounds. In hypokalemia, decreased bowel sounds are common due to slowed peristalsis. Hyperactive reflexes (choice A) and increased deep tendon reflexes (choice D) are more indicative of hyperkalemia. A strong, bounding pulse (choice B) is not typically associated with hypokalemia.

4. A client has hypoglycemia and is conscious. Which of the following actions should the nurse take?

• A. Administer glucagon IM
• B. Give the client 4 oz of fruit juice
• C. Provide the client with peanut butter
• D. Give the client 1 L of water

Correct answer: B

Rationale: In conscious clients with hypoglycemia, the most appropriate action is to provide a rapidly absorbed carbohydrate source like fruit juice to raise blood glucose levels quickly. Administering glucagon intramuscularly (IM) is usually reserved for unconscious clients or those who are unable to take oral glucose. Providing peanut butter or water would not rapidly address the hypoglycemic state as fruit juice would.

5. The nurse is caring for an 80-year-old client with Parkinson's disease. Which of the following nursing goals is MOST realistic and appropriate in planning care for this client?

• A. Facilitate the client in returning to usual activities of daily living
• B. Maintain optimal function within the client's limitations
• C. Assist the client in preparing for a peaceful and dignified death
• D. Delay the progression of the disease process in the client

Correct answer: B

Rationale: Maintaining optimal function within the client's limitations is the most realistic and appropriate nursing goal when caring for an 80-year-old client with Parkinson's disease. This goal focuses on maximizing the client's abilities and quality of life while acknowledging the impact of the disease. Option A is less realistic as returning to usual activities may not always be achievable in the case of Parkinson's disease. Option C is not appropriate as it does not address the client's current condition and care needs. Option D is less realistic as Parkinson's disease is progressive, and delaying its progression may not be entirely feasible.

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