Nursing Elites

1. A nurse is preparing to perform an abdominal assessment on a client. Which action should the nurse take first?

• A. Percuss the abdomen
• B. Inspect the abdomen
• C. Auscultate before palpation
• D. Palpate the abdomen

Correct answer: C

Rationale: The correct answer is to auscultate before palpation. This ensures that bowel sounds are not altered by physical manipulation. Inspecting the abdomen is a valid step but not the first. Percussing and palpating should come after auscultation to prevent altering bowel sounds or causing discomfort to the client.

2. A nurse is providing discharge teaching to a client with a new diagnosis of hypertension. What instruction should the nurse include?

• A. Reduce sodium intake to 4 grams per day
• B. Avoid foods high in potassium
• C. Take prescribed antihypertensive medications daily
• D. Limit fluid intake to 1 liter per day

Correct answer: C

Rationale: The correct answer is C: 'Take prescribed antihypertensive medications daily.' When providing discharge teaching to a client with hypertension, one of the key instructions is to ensure the consistent intake of prescribed antihypertensive medications. This is crucial for controlling blood pressure levels and reducing the risk of complications associated with hypertension. Choices A, B, and D are incorrect because reducing sodium intake, avoiding foods high in potassium, and limiting fluid intake are important dietary modifications for various health conditions, but they are not the priority when it comes to managing hypertension. The primary focus should be on medication adherence to effectively manage hypertension.

3. A nurse is reviewing a client's health history and identifies urinary incontinence as a risk factor for pressure injuries. What should the nurse include in the plan of care?

• A. Use a heating pad for comfort
• B. Apply a barrier cream to the skin
• C. Reposition the client every 4 hours
• D. Change the client's position every 2 hours

Correct answer: C

Rationale: The correct answer is to reposition the client every 4 hours. Repositioning the client helps prevent pressure injuries caused by urinary incontinence by relieving pressure on vulnerable areas of the skin. Choice A, using a heating pad for comfort, is not directly related to preventing pressure injuries. Choice B, applying a barrier cream to the skin, may help protect the skin but does not address the underlying cause of pressure injuries. Choice D, changing the client's position every 2 hours, is more frequent than necessary and may not be as effective in preventing pressure injuries as repositioning every 4 hours.

4. A nurse is providing discharge instructions to a client with a prescription for home oxygen therapy. What information should the nurse include?

• A. Use synthetic fabrics to avoid static electricity
• B. Turn off the oxygen when not in use
• C. Avoid open flames or smoking near oxygen
• D. Increase the oxygen flow rate as needed

Correct answer: C

Rationale: The correct answer is C: 'Avoid open flames or smoking near oxygen.' This information is crucial to prevent fires because oxygen supports combustion. Choices A, B, and D are incorrect. Choice A is not relevant to oxygen therapy. Choice B is incorrect as oxygen should not be turned off when in use as prescribed. Choice D is incorrect because adjusting the oxygen flow rate without healthcare provider guidance can be dangerous.

5. A nurse is assessing the IV infusion site of a client who reports pain at the site. The site is red, and there is warmth along the course of the vein. What should the nurse do?

• A. Increase the IV flow rate
• B. Discontinue the infusion
• C. Elevate the limb
• D. Apply a cold compress

Correct answer: B

Rationale: The correct answer is to discontinue the infusion (Choice B) as the signs described suggest phlebitis, an inflammation of the vein. Increasing the IV flow rate (Choice A) can exacerbate the condition by increasing the irritation. Elevating the limb (Choice C) and applying a cold compress (Choice D) are not the appropriate interventions for phlebitis. Elevation and cold therapy are more suitable for conditions like swelling or inflammation, but in this case, discontinuing the infusion is the priority to prevent further complications.

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