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. A nurse is providing teaching to a client who is postoperative following a cataract extraction. Which of the following statements should the nurse include?

• A. You should expect to have eye pain for the first 2 days after surgery.
• B. You should bend at the waist to pick up objects from the floor.
• C. You should avoid sleeping on the side of the body that was operated on.
• D. You should wear an eye shield at night for 2 weeks.

Correct answer: D

Rationale: The correct answer is D. After cataract surgery, wearing an eye shield at night for 2 weeks is essential to protect the eye during the initial healing period. Choice A is incorrect because significant eye pain should not be expected for the first 2 days after surgery. Choice B is incorrect as bending at the waist can increase intraocular pressure, which should be avoided postoperatively. Choice C is incorrect as there is no need to avoid sleeping on the side of the body that was operated on after cataract surgery.

3. A nurse is providing discharge teaching to a client who has had a total hip arthroplasty. Which of the following client statements indicates a need for further teaching?

• A. I will avoid sitting in a chair for longer than 30 minutes.
• B. I will avoid crossing my legs when sitting.
• C. I will bend at the hips to pick up items from the floor.
• D. I will avoid using a raised toilet seat.

Correct answer: C

Rationale: The correct answer is C because bending at the hips can dislocate the hip joint in clients who have had a total hip arthroplasty. This movement should be avoided to prevent complications post-surgery. Choices A, B, and D are all correct statements for a client who has had a total hip arthroplasty. Avoiding prolonged sitting, crossing legs, and using a raised toilet seat are all appropriate measures to ensure proper healing and prevent complications.

4. A nurse is caring for a client who has a new temporary synchronous pacemaker. Which of the following should the nurse report to the provider?

• A. The client's pulse oximetry level is 96%.
• B. The client develops hiccups.
• C. The ECG shows pacing spikes after the QRS complex.
• D. The client's heart rate is 90 beats per minute.

Correct answer: C

Rationale: The correct answer is C. Pacing spikes after the QRS complex indicate a malfunction of the pacemaker and should be reported. Choice A is not directly related to the pacemaker function. Choice B, hiccups, are common and not typically associated with pacemaker issues. Choice D, a heart rate of 90 beats per minute, is within the normal range and does not indicate a pacemaker malfunction.

5. A client with a new diagnosis of type 1 diabetes mellitus is being taught by a nurse. Which of the following client statements indicates an understanding of the teaching?

• A. I will check my blood glucose levels only when I feel sick.
• B. I will inject insulin in the same spot each time.
• C. I will rotate injection sites within the same anatomical region.
• D. I will inject insulin only if my blood glucose level is above 200 mg/dL.

Correct answer: C

Rationale: The correct answer is C. Clients with type 1 diabetes should rotate injection sites within the same anatomical region to prevent lipodystrophy. Choice A is incorrect because blood glucose levels should be checked regularly, not only when feeling sick. Choice B is incorrect as injecting insulin in the same spot each time can lead to lipodystrophy. Choice D is incorrect as insulin injections are usually required based on meal schedules and blood glucose levels, not just when levels are above 200 mg/dL.

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