Nursing Elites

1. A nurse is preparing to insert an indwelling urinary catheter for a client. Which of the following actions should the nurse take?

• A. Insert the catheter 7.5 cm (3 in) into the urethra.
• B. Insert the catheter until urine flow is established.
• C. Cleanse the catheter with sterile water before insertion.
• D. Insert the catheter 5 cm (2 in) into the urethra.

Correct answer: B

Rationale: The correct action for the nurse is to insert the catheter until urine flow is established. This helps ensure proper placement and reduces the risk of trauma. Choice A (7.5 cm) and Choice D (5 cm) provide specific measurements that may not be appropriate for all individuals as catheter insertion depth can vary. Choice C is incorrect as catheters should be cleansed with an appropriate solution such as sterile saline, not sterile water.

2. A nurse is caring for a client who has experienced intimate partner violence. What is the nurse's priority?

• A. Develop a safety plan with the client.
• B. Refer the client to a community support group.
• C. Determine if the client has any injuries.
• D. Contact the client's family about the incident.

Correct answer: A

Rationale: The correct answer is A: 'Develop a safety plan with the client.' When caring for a client who has experienced intimate partner violence, the nurse's priority is to ensure the client's safety. Developing a safety plan is essential to address the immediate safety concerns and provide support to the client. Referring the client to a community support group, as in option B, may be beneficial but is not the immediate priority. While determining if the client has any injuries, as in option C, is important for assessing physical well-being, the priority is to address safety concerns first. Contacting the client's family about the incident, as in option D, is not appropriate without the client's consent and may further endanger the client.

3. A client is receiving radiation therapy to the head and neck. Which of the following interventions should the nurse include?

• A. Instruct the client to use an alcohol-free mouthwash.
• B. Apply heat packs to the radiation site.
• C. Provide a diet low in carbohydrates.
• D. Avoid exposure to direct sunlight during treatment.

Correct answer: D

Rationale: The correct intervention for a client receiving radiation therapy to the head and neck is to avoid exposure to direct sunlight. Direct sunlight should be avoided to protect the skin from further irritation and damage caused by the radiation therapy. Instructing the client to use an alcohol-free mouthwash is important to prevent irritation and maintain oral hygiene, making choice A incorrect. Applying heat packs to the radiation site is contraindicated as heat can further aggravate the skin, making choice B incorrect. Providing a diet low in carbohydrates is not directly related to radiation therapy to the head and neck, so choice C is also incorrect.

4. A client receiving chemotherapy is being taught about infection prevention by a nurse. Which of the following instructions should the nurse include?

• A. Wear a mask when gardening.
• B. Avoid crowds to reduce the risk of infection.
• C. You should take a daily vitamin to prevent infection.
• D. Increase your intake of high-protein foods.

Correct answer: B

Rationale: The correct answer is B: 'Avoid crowds to reduce the risk of infection.' Clients receiving chemotherapy are immunocompromised, so avoiding crowds can help decrease the likelihood of exposure to infections. Wearing a mask when gardening (choice A) is important but not directly related to infection prevention in the context of chemotherapy. Taking a daily vitamin (choice C) may be beneficial for overall health but is not specifically focused on infection prevention. Increasing intake of high-protein foods (choice D) is essential for nutrition but does not directly address infection prevention.

5. A nurse is caring for a client who is in labor and receiving electronic fetal monitoring. The nurse is reviewing the monitor tracing and notes early decelerations. What should the nurse expect?

• A. Fetal hypoxia
• B. Abruptio placentae
• C. Post maturity
• D. Head compression

Correct answer: D

Rationale: Corrected Rationale: Early decelerations are caused by head compression resulting from the fetal head being compressed during contractions. They are considered benign and do not indicate fetal distress. Choice A, fetal hypoxia, is incorrect because early decelerations are not associated with fetal hypoxia. Choice B, abruptio placentae, is incorrect as it is a condition where the placenta prematurely separates from the uterine wall. Choice C, post maturity, is incorrect as it refers to a fetus that remains in the uterus past the due date.

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