Nursing Elites

1. A client who has an indwelling catheter reports a need to urinate. Which of the following actions should the nurse take?

• A. Check the catheter to see whether it is patent.
• B. Reassure the client that it is not possible for them to urinate.
• C. Re-catheterize the bladder with a larger-gauge catheter.
• D. Collect a urine specimen for analysis.

Correct answer: A

Rationale: When a client with an indwelling catheter reports a need to urinate, the nurse's initial action should be to check the catheter for patency. This is crucial to ensure that the catheter is not blocked, twisted, or kinked, which could lead to urinary retention. Reassuring the client without assessing the catheter could delay necessary interventions. Re-catheterizing the bladder with a larger-gauge catheter should not be the first step unless catheter patency is confirmed as an issue. Collecting a urine specimen for analysis is important but not the immediate priority when the client reports a need to urinate.

2. A client with diabetes mellitus is learning to self-administer insulin. Which action by the client indicates the need for further teaching?

• A. The client rotates injection sites on the abdomen.
• B. The client draws up the insulin dose after warming the vial to room temperature.
• C. The client pinches the skin before injecting the insulin.
• D. The client injects the insulin at a 90-degree angle.

Correct answer: B

Rationale: Drawing up insulin after warming the vial to room temperature indicates a need for further teaching, as insulin should be at room temperature for administration. Choice A is correct as rotating injection sites helps prevent lipodystrophy. Choice C is correct as pinching the skin helps ensure proper subcutaneous injection. Choice D is correct as injecting insulin at a 90-degree angle is the recommended technique for subcutaneous injections.

3. The healthcare provider is assessing a client who has a chest tube in place following a pneumothorax. Which finding should be reported to the healthcare provider immediately?

• A. Bubbling in the water seal chamber
• B. Drainage greater than 70 ml/hour
• C. Tidaling in the water seal chamber
• D. Absence of breath sounds on the affected side

Correct answer: D

Rationale: The absence of breath sounds on the affected side is a critical finding that may indicate a tension pneumothorax, a life-threatening condition requiring immediate intervention. This situation can lead to a shift of the mediastinum and impaired ventilation. Bubbling in the water seal chamber is an expected finding in a chest tube drainage system and indicates proper functioning. Drainage greater than 70 ml/hour is a concern but does not require immediate reporting unless it continues at a high rate or is associated with other symptoms. Tidaling in the water seal chamber is a normal fluctuation and indicates the chest tube system is patent and functioning correctly.

4. The nurse is caring for a client who was successfully resuscitated from a pulseless dysrhythmia. Which of the following assessments is MOST critical for the nurse to include in the plan of care?

• A. Hourly urine output
• B. White blood cell count
• C. Blood glucose every 4 hours
• D. Temperature every 2 hours

Correct answer: A

Rationale: Monitoring hourly urine output is crucial after successful resuscitation from a pulseless dysrhythmia to assess kidney function and perfusion. The kidneys are particularly vulnerable to injury following cardiac events due to decreased perfusion during the event. Evaluating urine output hourly allows for early detection of renal impairment or inadequate organ perfusion. Option B, monitoring white blood cell count, is not a priority in this situation as it does not directly relate to immediate post-resuscitation care. Option C, checking blood glucose every 4 hours, is important but not as critical as assessing kidney function and perfusion. Option D, measuring temperature every 2 hours, is relevant for monitoring signs of infection or inflammatory response but is not as crucial as assessing kidney function in this scenario.

5. A client is recovering from gallbladder surgery performed under general anesthesia. How many times per hour should the nurse encourage the client to use the incentive spirometer?

• A. 4-5 times per hour
• B. 2-3 times per hour
• C. 6-7 times per hour
• D. 8-10 times per hour

Correct answer: A

Rationale: Encouraging the client to use the incentive spirometer 4-5 times per hour is the correct approach post-gallbladder surgery under general anesthesia. This frequency helps prevent respiratory complications, such as atelectasis, by promoting lung expansion. Choices B, C, and D suggest either too few or too many sessions per hour, which may not be optimal for the client's respiratory recovery needs. It is important to strike a balance between ensuring adequate lung expansion and not overexerting the client, which is why 4-5 times per hour is the recommended frequency.

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