Nursing Elites

1. A nurse is reviewing a client's health history and identifies chronic constipation as a potential complication of immobility. What intervention should the nurse include in the plan of care?

• A. Increase fiber intake
• B. Encourage the client to walk daily
• C. Use a stool softener as needed
• D. Use a laxative daily

Correct answer: A

Rationale: Increasing fiber intake is the appropriate intervention to include in the plan of care for a client with chronic constipation due to immobility. Fiber helps add bulk to the stool, making it easier to pass, thereby preventing constipation. Encouraging the client to walk daily (choice B) is also beneficial as it promotes mobility and can help alleviate constipation associated with immobility. Using a stool softener as needed (choice C) and using a laxative daily (choice D) are not the first-line interventions for managing constipation related to immobility. Stool softeners and laxatives should be used judiciously and under healthcare provider guidance.

2. 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.

3. A nurse is assessing a client who is at risk for pressure injuries. Which intervention should the nurse include in the plan of care?

• A. Reposition the client every 4 hours
• B. Use a special mattress for the client
• C. Keep the client on bedrest
• D. Encourage the client to remain in one position

Correct answer: B

Rationale: The correct answer is B: 'Use a special mattress for the client.' Using a special mattress reduces pressure on bony prominences and helps prevent pressure injuries. Repositioning the client every 4 hours (choice A) is important but using a special mattress is more effective. Keeping the client on bedrest (choice C) can increase the risk of pressure injuries due to prolonged immobility. Encouraging the client to remain in one position (choice D) is incorrect as it can lead to pressure injuries by exerting pressure on the same areas for an extended period.

4. A nurse is teaching a group of assistive personnel about expected integumentary changes in older adults. What change should the nurse include?

• A. Increase in oil production
• B. Decrease in elasticity
• C. Increase in pigmentation
• D. Decrease in moisture levels

Correct answer: B

Rationale: The correct answer is B: Decrease in elasticity. As individuals age, their skin tends to lose elasticity, becoming less flexible. This results in wrinkles and sagging skin. Option A, increase in oil production, is not typically an expected integumentary change in older adults. Option C, increase in pigmentation, may occur due to sun exposure or age spots but is not a universal change. Option D, decrease in moisture levels, is not a primary integumentary change associated with aging.

5. A healthcare provider is performing a cultural assessment of a group of clients to maintain respect for their value systems and beliefs. Which of the following should the provider identify as examples of cultural variables?

• A. Health literacy, income, gender
• B. Eye contact, personal space, touch
• C. Physical activity, ethnicity, eye contact
• D. Body language, facial expressions, religion

Correct answer: B

Rationale: The correct answer is B: Eye contact, personal space, and touch are cultural variables that can influence healthcare interactions. These factors vary across cultures and can impact how individuals perceive communication and interactions. Choices A, C, and D include elements that are not specifically cultural variables affecting communication and interactions in the same way as eye contact, personal space, and touch.

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