Nursing Elites

1. A client who had an abdominal hysterectomy is experiencing minimal urine output despite adequate fluid intake. What should the nurse assess first?

• A. The client's bladder for distension.
• B. The IV catheter insertion site.
• C. The patency of the urinary catheter.
• D. The client's vital signs.

Correct answer: C

Rationale: Assessing the patency of the urinary catheter is crucial in this situation. A blocked catheter could be a common cause of decreased urine output following surgery. While checking the IV catheter insertion site (Choice B) is important, it is not the priority in this case. Examining the client's bladder for distension (Choice A) is relevant, but assessing the patency of the catheter takes precedence in resolving the issue of decreased urine output. Monitoring vital signs (Choice D) is a routine nursing task but not the priority when dealing with decreased urine output post-surgery.

2. During a routine prenatal visit at the antepartal clinic, a multipara at 35-weeks gestation presents with 2+ edema of the ankles and feet. Which additional information should the PN report to the RN?

• A. Due date
• B. Blood pressure
• C. Gravida and parity
• D. Fundal height

Correct answer: B

Rationale: Blood pressure is the most critical information to report to the RN in this scenario. The presence of edema, along with high blood pressure, can be indicative of preeclampsia, a severe condition in pregnancy. Monitoring blood pressure is essential for assessing the patient's condition and taking appropriate actions if necessary. Choices A, C, and D are not as urgent in this situation. The due date, gravida, and parity are important for overall assessment but do not address the immediate concern of potential preeclampsia. Fundal height is used to assess fetal growth and position but is not the priority when edema and high blood pressure are present.

3. A registered nurse is preparing to hang the first bag of total parenteral nutrition (TPN) solution. The client has a central line, and this is the first bag he will receive. Which of the following is the most essential piece of equipment to obtain prior to hanging the bag?

• A. Blood glucose meter
• B. Noninvasive blood pressure monitor
• C. Electronic infusion pump
• D. Urine test strips

Correct answer: C

Rationale: An electronic infusion pump is essential for administering TPN to ensure accurate delivery and avoid complications such as fluid overload or improper nutrient delivery. The pump helps regulate the flow rate precisely, which is crucial when infusing TPN. Monitoring the client's blood glucose is important but not immediately necessary before hanging the TPN bag. A noninvasive blood pressure monitor is not directly related to administering TPN and is not the most essential equipment needed for this procedure. Urine test strips are not required for administering TPN via a central line and are not essential equipment for this specific task.

4. A client who is at full-term gestation is in active labor and complains of a cramp in her leg. Which intervention should the nurse implement?

• A. Massage the calf and foot
• B. Elevate the leg above the heart
• C. Check the pedal pulse in the affected leg
• D. Extend the leg and flex the foot

Correct answer: D

Rationale: The correct intervention for a client in active labor complaining of a leg cramp is to extend the leg and flex the foot. This action helps stretch the muscles that are cramping, providing relief. Massaging the calf and foot (Choice A) may not be as effective for relieving the cramp. Elevating the leg above the heart (Choice B) is not indicated for a leg cramp. Checking the pedal pulse in the affected leg (Choice C) is unrelated to addressing the leg cramp.

5. Which is the most important safety measure when administering a medication through a patient’s central venous catheter (CVC)?

• A. Using a sterile technique
• B. Ensuring correct placement of the CVC
• C. Flushing the CVC with saline after administration
• D. Monitoring for signs of infection

Correct answer: B

Rationale: The most important safety measure when administering a medication through a patient’s central venous catheter (CVC) is ensuring the correct placement of the CVC. This is crucial to prevent complications such as extravasation, infection, or improper drug delivery. While using a sterile technique, flushing the CVC with saline after administration, and monitoring for signs of infection are all important aspects of CVC care, ensuring the correct placement of the catheter takes precedence as it directly impacts patient safety during medication administration.

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