Nursing Elites

1. The nurse is teaching a client with newly diagnosed type 1 diabetes about insulin administration. Which statement by the client indicates a need for further teaching?

• A. I will rotate my injection sites to avoid lipodystrophy.
• B. I will check my blood sugar before meals and at bedtime.
• C. I will use the same needle for 3 days if I keep it clean.
• D. I will keep my insulin refrigerated until I need it.

Correct answer: C

Rationale: The correct answer is C because insulin needles should be disposed of after a single use to prevent infection. Reusing the same needle for three days can lead to infection and is not a safe practice. Choices A, B, and D demonstrate good understanding of insulin administration and diabetes management, so they do not indicate a need for further teaching.

2. What is the most important action for the nurse to take to prevent infection in a client who has just returned from surgery with an indwelling urinary catheter in place?

• A. Change the catheter every 72 hours.
• B. Ensure the catheter tubing is free of kinks.
• C. Clean the perineal area with antiseptic solution daily.
• D. Irrigate the catheter with normal saline every shift.

Correct answer: B

Rationale: The most important action to prevent infection in a client with an indwelling urinary catheter is to ensure the catheter tubing is free of kinks. This action helps prevent obstruction, ensures proper drainage, and reduces the risk of infection. Changing the catheter every 72 hours is not necessary unless clinically indicated and may introduce unnecessary risk. Cleaning the perineal area with antiseptic solution daily is important for general hygiene but not the most critical action for catheter-related infection prevention. Irrigating the catheter with normal saline every shift is not a routine nursing intervention for catheter care and may increase the risk of introducing pathogens.

3. The nurse is providing discharge teaching to a client who has a new prescription for digoxin (Lanoxin). Which statement by the client indicates a need for further teaching?

• A. I will take my pulse before taking the medication.
• B. I will take the medication at the same time every day.
• C. I should avoid taking antacids at the same time as this medication.
• D. I should eat foods high in potassium while taking this medication.

Correct answer: D

Rationale: The correct answer is D. Clients taking digoxin should avoid eating foods high in potassium, as this can affect the medication's efficacy. Choices A, B, and C are correct statements regarding digoxin administration and precautions, indicating the client's understanding of the medication and its management.

4. A charge nurse is observing a newly licensed nurse perform tracheostomy care for a client. Which of the following actions by the newly licensed nurse requires intervention?

• A. Obtaining cotton balls for the tracheostomy care
• B. Using a sterile water bottle
• C. Checking the suction equipment
• D. Wearing a sterile gown

Correct answer: A

Rationale: The correct answer is A. Obtaining cotton balls for tracheostomy care is not recommended due to the risk of fiber contamination. Sterile gauze should be used instead. Choice B, using a sterile water bottle, is a correct and appropriate action for tracheostomy care to maintain cleanliness. Choice C, checking the suction equipment, is also a necessary step to ensure it is functioning properly for the procedure. Choice D, wearing a sterile gown, is a standard precaution to maintain a sterile environment during tracheostomy care.

5. A client on a telemetry unit is being cared for by a nurse after a myocardial infarction. The client expresses, 'All this equipment is making me nervous.' Which of the following responses should the nurse make?

• A. 'All of this equipment can be frightening.'
• B. 'The equipment is necessary to monitor your condition.'
• C. 'You should try to ignore the equipment.'
• D. 'Try to relax; the equipment is not harmful.'

Correct answer: A

Rationale: Choice A is the most appropriate response as it acknowledges the client's feelings, showing empathy and understanding. It validates the client's experience, which can help reduce anxiety and build rapport. Choice B provides information but may not address the client's emotional needs. Choice C dismisses the client's concerns and does not offer support. Choice D minimizes the client's feelings and may not effectively address their anxiety.

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