Nursing Elites

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

• A. Inflate the balloon with 10 mL of sterile water prior to insertion
• B. Cleanse the client’s labia and meatus using a front-to-back motion
• C. Ask the client to bear down while inserting the catheter
• D. Inflate the catheter balloon after urine begins to flow

Correct answer: D

Rationale: The correct action for the nurse to take when inserting an indwelling urinary catheter into a female client is to inflate the catheter balloon after urine begins to flow. Inflating the balloon before urine starts flowing can lead to incorrect placement in the urethra, causing trauma. Cleansing the labia and meatus should be done before the insertion, but the crucial step of inflating the balloon should occur after the catheter is correctly placed. Asking the client to bear down is not necessary during catheter insertion.

2. A nurse at a provider’s office is interviewing a client who has multiple sclerosis and has been taking dantrolene for several months. Which of the following client statements should the nurse identify as an indication that the medication is effective?

• A. “I don’t have muscle spasms as frequently.”
• B. “I haven’t gotten any colds, even though it is flu season.”
• C. “I feel like my nerve pain has improved.”
• D. “It is easier to urinate now.”

Correct answer: A

Rationale: The correct answer is A: "I don’t have muscle spasms as frequently." The nurse should identify that dantrolene relaxes skeletal muscles, so a decrease in muscle spasms indicates the medication is effective. Choice B is incorrect as cold prevention is not related to dantrolene. Choice C is incorrect because nerve pain improvement is not a direct effect of dantrolene. Choice D is incorrect as dantrolene's action does not affect urination.

3. A client with a history of seizures is being cared for by a nurse. Which of the following interventions should the nurse prioritize?

• A. Ensure the environment is safe
• B. Administer medications as prescribed
• C. Monitor for signs of infection
• D. Educate the client about triggers

Correct answer: A

Rationale: The nurse should prioritize ensuring the environment is safe for a client with a history of seizures. This intervention is crucial to prevent injury during a seizure. Administering medications as prescribed is important but ensuring a safe environment takes precedence to prevent harm. Monitoring for signs of infection and educating the client about triggers are also essential aspects of care but are not the priority when considering the immediate safety of the client during a seizure.

4. A nurse is providing discharge instructions about breast engorgement to a client who has decided not to breastfeed. Which of the following statements by the client indicates a need for further instruction?

• A. I can wear a supportive bra
• B. I will apply cold compresses to my breasts
• C. I will manually express breast milk
• D. I can take a mild analgesic

Correct answer: C

Rationale: The correct answer is C. Manually expressing breast milk will stimulate more milk production, which contradicts the goal of reducing milk supply in clients who choose not to breastfeed. Choices A, B, and D are correct statements that can help relieve breast engorgement without promoting further milk production.

5. A nurse is assessing a 1-hour postpartum client and notes a boggy uterus located 2 cm above the umbilicus. Which of the following actions should the nurse take first?

• A. Take vital signs
• B. Assess lochia
• C. Massage the fundus
• D. Give oxytocin IV bolus

Correct answer: C

Rationale: When a nurse assesses a 1-hour postpartum client with a boggy uterus located 2 cm above the umbilicus, it indicates uterine atony. The first action the nurse should take is to massage the fundus. Fundal massage helps stimulate uterine contractions, which will reduce bleeding and prevent postpartum hemorrhage. Taking vital signs, assessing lochia, or administering an oxytocin IV bolus are important interventions but should come after addressing uterine atony through fundal massage.

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