Nursing Elites

1. A healthcare professional is preparing to administer a cleansing enema to a client. Which of the following actions should the healthcare professional plan to take?

• A. Insert the rectal tube 15.2 cm (6 inches) into the client's rectum
• B. Wear clean gloves before inserting the tubing
• C. Position the client on their left side
• D. Hold the solution bag 91 cm (36 inches) above the client's rectum

Correct answer: C

Rationale: Positioning the client on their left side is crucial when administering an enema as it helps facilitate the flow of the solution into the sigmoid and descending colon. This position allows gravity to assist in the process. Placing the client on the left side is a standard practice to promote optimal outcomes during the procedure. Choices A, B, and D are incorrect. Choice A provides a specific measurement for the insertion depth of the rectal tube, which is not typically necessary to include in the plan of action. Choice B is essential but not specific to enema administration. Choice D mentions holding the solution bag without specifying the correct height, which should typically be around 18-24 inches above the rectum for a cleansing enema.

2. When teaching a client how to perform self-catheterization, which of the following instructions should be included?

• A. Use sterile gloves during the procedure.
• B. Clean the catheter with alcohol after each use.
• C. Insert the catheter 2-4 inches into the urethra.
• D. Perform the procedure every 8 hours.

Correct answer: C

Rationale: To ensure effective drainage, the catheter should be inserted 2-4 inches into the urethra. This length allows the catheter to reach the bladder, bypass the urethral sphincters, and ensure proper drainage without causing discomfort or injury. Using sterile gloves, cleaning the catheter with alcohol, and performing the procedure every 8 hours are not accurate instructions for self-catheterization.

3. When should discharge planning begin for a client admitted to a long-term care facility for rehabilitation after a total hip arthroplasty?

• A. One week prior to the client's discharge
• B. Upon the client's admission to the care facility
• C. Once the discharge date is identified
• D. When the client addresses the topic with the nurse

Correct answer: B

Rationale: Discharge planning should begin upon the client's admission to the care facility. This early start allows the healthcare team to conduct assessments, set goals, and coordinate services for a smooth transition back home or to the community. Initiating discharge planning early ensures timely arrangements, leading to optimal outcomes and continuity of care. Choices A, C, and D are incorrect because waiting until one week before discharge, after the discharge date is identified, or until the client brings up the topic may lead to rushed decision-making, inadequate arrangements, and a less effective transition process.

4. A client has a new diagnosis of hypertension and is being taught about dietary management. Which of the following client statements indicates an understanding of the teaching?

• A. I will increase my intake of dairy products.
• B. I will eat more fresh fruits and vegetables.
• C. I will limit my intake of whole grains.
• D. I will consume more red meat.

Correct answer: B

Rationale: The correct answer is B because increasing the intake of fresh fruits and vegetables can help manage blood pressure. These foods are rich in nutrients like potassium, fiber, and antioxidants, which are beneficial for individuals with hypertension. Dairy products are usually high in saturated fats, which can be detrimental to blood pressure control. Whole grains are generally recommended for their health benefits, including maintaining a healthy weight and heart health. Red meat is often high in saturated fats and can contribute to high blood pressure and other cardiovascular risks.

5. A client with a new diagnosis of type 1 diabetes mellitus is being taught by a nurse. Which of the following statements should the nurse include in the teaching?

• A. You can still eat sugar, but you must count it in your carbohydrate count for the day.
• B. You need to avoid all forms of sugar to keep your blood glucose levels under control.
• C. You can eat unlimited amounts of proteins and fats since they do not affect blood glucose levels.
• D. You will need to take an oral hypoglycemic agent every day to manage your blood glucose levels.

Correct answer: A

Rationale: The correct statement to include in teaching a client with type 1 diabetes mellitus is that they can still eat sugar, but they must count it in their carbohydrate intake for the day. This is important because clients with type 1 diabetes need to manage their blood glucose levels by calculating their carbohydrate intake, including sugars. Choice B is incorrect because total avoidance of sugar is not necessary, but monitoring and including it in the carbohydrate count is essential. Choice C is incorrect as proteins and fats can also affect blood glucose levels and should be consumed in moderation. Choice D is incorrect since oral hypoglycemic agents are not used in type 1 diabetes mellitus, as insulin replacement therapy is the mainstay of treatment.

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