Nursing Elites

1. A nurse is assessing a client who is postoperative following abdominal surgery and has an indwelling urinary catheter that is draining dark yellow urine at 25 ml/hr. What intervention should the nurse anticipate?

• A. Clamp the catheter.
• B. Administer a fluid bolus.
• C. Obtain a urine specimen for culture and sensitivity.
• D. Initiate continuous bladder irrigation.

Correct answer: D

Rationale: In this scenario, the nurse should anticipate initiating continuous bladder irrigation. Dark yellow urine output at a rate of 25 ml/hr following abdominal surgery may indicate urinary stasis or obstruction, which could lead to complications like urinary retention. Continuous bladder irrigation helps prevent catheter obstruction and manage urinary retention by ensuring patency and promoting urine flow. Clamping the catheter (Choice A) could lead to urinary stasis and should be avoided. Administering a fluid bolus (Choice B) is not indicated solely based on the urine color and output described. Obtaining a urine specimen for culture and sensitivity (Choice C) may be necessary for assessing infection but does not directly address the issue of urinary stasis or obstruction.

2. How should a healthcare provider monitor a patient who has been prescribed digoxin?

• A. Monitor potassium levels
• B. Monitor heart rate
• C. Check digoxin levels
• D. Check blood glucose levels

Correct answer: C

Rationale: The correct way to monitor a patient who has been prescribed digoxin is by checking digoxin levels. Digoxin is a medication used to treat various heart conditions, and monitoring its levels in the blood is crucial to prevent toxicity. Monitoring potassium levels (Choice A) is important as well, as digoxin can affect potassium levels, but checking digoxin levels is more specific to monitoring the medication itself. Monitoring heart rate (Choice B) is relevant but does not directly assess the medication levels. Checking blood glucose levels (Choice D) is not typically indicated specifically for patients prescribed digoxin.

3. What is the recommended dietary restriction for a patient with chronic kidney disease?

• A. Limit potassium intake
• B. Limit fluid intake
• C. Increase protein intake
• D. Increase carbohydrate intake

Correct answer: B

Rationale: The correct answer is to limit fluid intake for a patient with chronic kidney disease. This restriction helps manage fluid balance to prevent fluid overload. Choices A, C, and D are incorrect. Limiting potassium intake is essential for some patients with kidney disease, but it is not the primary dietary restriction. Increasing protein intake is usually not recommended due to the impaired kidney function in these patients. Increasing carbohydrate intake is also not a standard recommendation for patients with chronic kidney disease.

4. A client requests the creation of a living will. Which of the following actions should the nurse take?

• A. Schedule a meeting between the hospital ethics committee and the client
• B. Evaluate the client's understanding of life-sustaining measures
• C. Determine the client's preferences about post-mortem care
• D. Request a conference with the client's family

Correct answer: B

Rationale: The correct action for the nurse to take when a client requests the creation of a living will is to evaluate the client's understanding of life-sustaining measures. This step is crucial to ensure that the client is well-informed about their options before making decisions regarding their future care. Scheduling a meeting with the hospital ethics committee (choice A) may not be necessary at this stage and could overwhelm the client. Determining the client's preferences about post-mortem care (choice C) is not directly related to creating a living will. Requesting a conference with the client's family (choice D) may be important later but is not the initial step in this situation.

5. A nurse is caring for a client who has pneumonia and is receiving oxygen therapy. Which of the following findings indicates the need for suctioning?

• A. Increased respiratory rate.
• B. Oxygen saturation 96%.
• C. Clear lung sounds.
• D. Productive cough.

Correct answer: A

Rationale: The correct answer is A: Increased respiratory rate. An increased respiratory rate suggests the client is having difficulty clearing secretions and may require suctioning. Oxygen saturation of 96% is within the normal range and indicates adequate oxygenation. Clear lung sounds suggest good air entry without the need for suctioning. A productive cough, although a symptom of pneumonia, does not directly indicate the need for suctioning.

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