Nursing Elites

1. A client is scheduled for a colonoscopy. What instruction should the nurse provide to prepare the client for the procedure?

• A. Drink clear liquids for 24 hours before the procedure
• B. Take a laxative the morning of the procedure
• C. Eat a light meal before the procedure
• D. Avoid drinking fluids for 4 hours before the procedure

Correct answer: A

Rationale: The correct instruction for preparing a client for a colonoscopy is to drink clear liquids for 24 hours before the procedure. This step helps to ensure the bowel is adequately cleared for the colonoscopy, allowing for better visualization and examination of the colon.

2. While instructing a male client's wife in the performance of passive range-of-motion exercises to his contracted shoulder, the nurse observes that she is holding his arm above and below the elbow. What nursing action should the nurse implement?

• A. Acknowledge that she is supporting the arm correctly.
• B. Encourage her to keep the joint uncovered to maintain warmth.
• C. Reinforce the need to grip directly under the joint for better support.
• D. Instruct her to grip directly over the joint for better motion.

Correct answer: A

Rationale: The wife is correctly performing the passive range-of-motion exercises by holding the arm above and below the elbow. The nurse should acknowledge this correct technique (A). It is essential to keep the joint uncovered (B) during exercises, while ensuring the rest of the body remains covered for warmth and privacy. Choices (C) and (D) do not provide optimal support to the joint for effective movement.

3. During a clinic visit, the mother of a 7-year-old reports to the nurse that her child is often awake until midnight playing and is then very difficult to awaken in the morning for school. Which assessment data should the nurse obtain in response to the mother's report?

• A. The occurrence of any episodes of sleep apnea
• B. The child's blood pressure, pulse, and respirations
• C. Length of rapid eye movement (REM) sleep that the child is experiencing
• D. Description of the family's home environment

Correct answer: D

Rationale: In response to the mother's report, the nurse should assess the family's home environment first to identify any factors that may hinder the establishment of bedtime routines conducive to sleep. Factors such as noise, light, distractions, or other environmental aspects could be contributing to the child's difficulty falling asleep at a reasonable hour and waking up in the morning.

4. Urinary catheterization is prescribed for a postoperative female client who has been unable to void for 8 hours. The nurse inserts the catheter, but no urine is seen in the tubing. Which action will the nurse take next?

• A. Clamp the catheter and recheck it in 60 minutes.
• B. Pull the catheter back 3 inches and redirect it upward.
• C. Leave the catheter in place and reattempt with another catheter.
• D. Notify the healthcare provider of a possible obstruction.

Correct answer: C

Rationale: In this scenario, if no urine is seen in the tubing after inserting the catheter, it is likely that the catheter is in the vagina rather than the bladder. Leaving the first catheter in place will help locate the meatus more easily when attempting the second catheterization. This approach ensures correct placement of the catheter in the bladder and minimizes the risk of causing unnecessary discomfort or trauma to the patient.

5. When culturing a wound, the nurse should obtain the sample from which part of the wound?

• A. The outer edges of the wound.
• B. All necrotic sections of the wound.
• C. Areas containing purulent or pooled exudates.
• D. Any particularly painful area of the wound.

Correct answer: C

Rationale: To collect a wound culture, the nurse should first clean the wound to remove skin flora and then insert a sterile swab from a culturette tube into the wound secretions.

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