Nursing Elites

1. 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.

2. A client with a new diagnosis of hypertension is receiving discharge teaching. What should the nurse emphasize regarding lifestyle changes?

• A. Limit sodium intake to 2 grams per day
• B. Increase fluid intake to 2 liters per day
• C. Avoid potassium-rich foods
• D. Avoid alcohol consumption

Correct answer: B

Rationale: The correct answer is to increase fluid intake to 2 liters per day. Adequate fluid intake helps manage hypertension and prevent fluid retention. Limiting sodium intake, avoiding potassium-rich foods, and abstaining from alcohol are important aspects of managing hypertension; however, in this scenario, emphasizing the increase in fluid intake is crucial for the client's understanding and compliance.

3. A nurse is assessing a client who has been receiving intermittent enteral feedings. What should the nurse identify as an intolerance to the feeding?

• A. Nausea
• B. Decreased heart rate
• C. Weight gain
• D. Fever

Correct answer: A

Rationale: Nausea is a common symptom of intolerance to enteral feedings. When a client experiences nausea during enteral feeding, it can indicate issues such as feeding tube placement problems, formula intolerance, or gastroparesis. Nausea can lead to vomiting and further complications if not addressed promptly. Decreased heart rate, weight gain, and fever are not typically associated with intolerance to enteral feedings and would not be the primary indicators for this situation.

4. A client expresses anxiety about an upcoming surgery. What should the nurse do?

• A. Administer a sedative
• B. Ask the client to describe their feelings
• C. Call the surgeon to address the anxiety
• D. Provide information on post-op care

Correct answer: B

Rationale: When a client expresses anxiety, it is essential for the nurse to encourage the client to verbalize their feelings. This helps the client express concerns, fears, and uncertainties, enabling the nurse to provide appropriate emotional support. Administering a sedative (Choice A) should not be the initial response as it does not address the underlying emotional needs of the client. Calling the surgeon to address anxiety (Choice C) may not be within the nurse's scope of practice and may not directly address the client's emotional needs. Providing information on post-op care (Choice D) is important but not the priority when the client is experiencing anxiety preoperatively.

5. A nurse is caring for a client who reports a decrease in the effectiveness of their arthritis medication. What factor should the nurse identify as contributing to this decrease?

• A. Improved mobility
• B. Bowel inflammation
• C. Long-term use of the medication
• D. Frequent dehydration

Correct answer: B

Rationale: The correct answer is B: Bowel inflammation. Bowel inflammation can decrease the absorption of medications, reducing their effectiveness. Improved mobility (choice A) would generally not contribute to a decrease in medication effectiveness. Long-term use of the medication (choice C) may lead to tolerance but would not directly cause a decrease in effectiveness. Frequent dehydration (choice D) can affect overall health but is not a direct factor in the medication's effectiveness for arthritis.

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