Nursing Elites

1. When inserting an indwelling urinary catheter in a female client and urine flows into the tubing, what is the next action?

• A. Document the color and clarity of the urine
• B. Insert the catheter an additional inch
• C. Ask the client to breathe deeply and slowly exhale
• D. Inflate the balloon with 5 mL of sterile water

Correct answer: D

Rationale: When urine flows into the tubing during the insertion of an indwelling urinary catheter, it confirms proper catheter placement. The next step should be to inflate the balloon with the specified amount of sterile water to secure the catheter in place. Documenting the color and clarity of the urine (choice A) is important for assessment but not the immediate next action. Inserting the catheter further (choice B) without securing it could cause harm. Asking the client to breathe deeply (choice C) is not relevant to this situation.

2. The nurse is caring for a client who underwent a total knee replacement yesterday. What activity level should the nurse encourage today?

• A. Bed rest with bathroom privileges only
• B. Frequent, short walks with assistance
• C. Range of motion exercises to the knee every four hours
• D. Leg elevation to reduce swelling

Correct answer: B

Rationale: After a total knee replacement, early ambulation is crucial for promoting circulation and preventing complications like thrombosis. Bed rest should be avoided as it can increase the risk of complications. Range of motion exercises are important but should be performed gradually and not excessively. Leg elevation is beneficial for reducing swelling but should not be the primary activity level encouraged immediately after surgery.

3. A client who has just been diagnosed with tuberculosis (TB) is being discharged home. Which instruction is most important for the nurse to provide?

• A. Avoid close contact with others until treatment is complete
• B. Take all prescribed medications as directed
• C. Schedule a follow-up appointment with the healthcare provider
• D. Wear a mask when in public places

Correct answer: B

Rationale: The correct answer is B: 'Take all prescribed medications as directed.' This instruction is the most important because adherence to the prescribed medication regimen is crucial in treating tuberculosis effectively and preventing the development of drug-resistant TB. While choice A is important for infection control, ensuring treatment adherence through proper medication intake takes precedence. Choice C is also essential for monitoring progress but is not as critical as ensuring medication compliance. Choice D is relevant for preventing transmission but is not as crucial as ensuring proper treatment by taking medications as directed.

4. A client with a diagnosis of rheumatoid arthritis is prescribed methotrexate. What is the primary action of this medication?

• A. Increases joint lubrication
• B. Reduces inflammation by suppressing the immune system
• C. Enhances bone density
• D. Stimulates cartilage regeneration

Correct answer: B

Rationale: The correct answer is B: Methotrexate is an immunosuppressant that works by suppressing the immune system, thereby reducing inflammation in rheumatoid arthritis. Methotrexate does not directly increase joint lubrication (Choice A) as its primary action is on the immune system. Choices C and D are incorrect since methotrexate does not enhance bone density or stimulate cartilage regeneration. It is crucial for healthcare providers to understand the mechanism of action of medications to provide safe and effective care to patients.

5. A client is admitted to the hospital with second and third degree burns to the face and neck. How should the nurse best position the client to maximize function of the neck and face and prevent contracture?

• A. The neck extended backward using a rolled towel behind the neck
• B. Prone position using pillows to support both arms outward from the torso
• C. Side-lying position using pillows to support the abdomen and back
• D. The neck forward using pillows under the head and sandbags on both sides

Correct answer: D

Rationale: After sustaining burns to the face and neck, positioning is crucial to maintain functional posture, reduce pain, and prevent contractures. Placing the neck forward using pillows under the head and sandbags on both sides is the best option in this scenario. This position helps prevent neck and facial contractures, allowing for optimal function and healing. Choices A, B, and C do not adequately address the specific needs of a client with burns to the face and neck. Choice A could potentially exacerbate neck contractures, Choice B focuses on arm support rather than neck and face positioning, and Choice C does not directly address the needs of the burned face and neck, making them less effective in preventing contractures in these critical areas.

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