Nursing Elites

1. A client needs a 24-hour urine collection initiated. Which of the following client statements indicates an understanding of the procedure?

• A. I had a bowel movement, but I was able to save the urine.
• B. I have a specimen in the bathroom from about 30 minutes ago.
• C. I flushed what I urinated at 7 am and have saved the rest since.
• D. I drink a lot, so I will fill up the bottle and complete the test quickly.

Correct answer: C

Rationale: Choice C is correct because it demonstrates the client's understanding of the procedure, which involves discarding the first urine of the day at the specified time and then saving all subsequent urine for the next 24 hours. Choices A, B, and D do not reflect an understanding of the correct procedure. Choice A is incorrect because bowel movements are not part of a 24-hour urine collection. Choice B is incorrect as it does not specify discarding the first urine. Choice D is incorrect as it mentions filling up the bottle quickly, which is not the correct way to collect a 24-hour urine sample.

2. What is the most important step when preparing to administer a blood transfusion?

• A. Check if the client has a fever
• B. Ensure the blood type is compatible with the client
• C. Administer the blood via IV push
• D. Ensure the blood is warmed to body temperature

Correct answer: B

Rationale: The correct answer is B: Ensure the blood type is compatible with the client. This is the most crucial step in preparing for a blood transfusion to prevent severe transfusion reactions. Checking the client for a fever (Choice A) is important but not the most critical step. Administering blood via IV push (Choice C) is incorrect as blood transfusions are usually administered as a slow drip. Warming the blood to body temperature (Choice D) is not a standard practice and can lead to hemolysis, making it an incorrect choice.

3. How should a healthcare provider assess a patient for fluid overload?

• A. Monitor weight and assess for shortness of breath
• B. Auscultate lung sounds and monitor blood pressure
• C. Assess for edema in the extremities
• D. Assess for jugular venous distension

Correct answer: A

Rationale: Correctly, the answer is to monitor weight and assess for shortness of breath when assessing a patient for fluid overload. Weight monitoring is crucial as sudden weight gain can indicate fluid retention. Shortness of breath can be a sign of fluid accumulation in the lungs. While auscultating lung sounds and monitoring blood pressure are important assessments in overall patient care, they may not be specific to fluid overload. Assessing for edema in the extremities is relevant, but it is not as sensitive as monitoring weight for detecting fluid overload. Assessing for jugular venous distension is more specific to assessing fluid status in heart failure rather than a general assessment for fluid overload.

4. A client with chronic obstructive pulmonary disease (COPD) is being taught by a nurse about measures to improve breathing. Which of the following instructions should the nurse include?

• A. Use pursed-lip breathing during physical activity
• B. Breathe deeply and quickly during exercise
• C. Avoid using the incentive spirometer
• D. Avoid physical activity to conserve energy

Correct answer: A

Rationale: The correct instruction the nurse should include is to 'Use pursed-lip breathing during physical activity.' Pursed-lip breathing is a technique that helps improve breathing efficiency in individuals with COPD by preventing airway collapse and allowing for better air exchange. Choice B is incorrect because breathing deeply and quickly can lead to hyperventilation and worsen symptoms in COPD patients. Choice C is incorrect because the incentive spirometer is a device used to encourage deep breathing and improve lung function, so it should not be avoided. Choice D is incorrect because physical activity is important for maintaining overall health and should be encouraged in a controlled and appropriate manner for individuals with COPD.

5. A nurse is reviewing the laboratory results of a client who is undergoing screening for prostate cancer. The nurse should expect an elevation in which of the following laboratory values?

• A. Prostate-specific antigen (PSA)
• B. Human chorionic gonadotropin (hCG)
• C. Alpha-fetoprotein (AFP)
• D. Carcinoembryonic antigen (CEA)

Correct answer: A

Rationale: The correct answer is A: Prostate-specific antigen (PSA). PSA is a marker specifically used for prostate cancer screening. Elevated levels of PSA can indicate prostate cancer or other prostate-related issues, prompting the need for further diagnostic investigations. Choices B, C, and D are not typically associated with prostate cancer screening. Human chorionic gonadotropin (hCG) is related to pregnancy, alpha-fetoprotein (AFP) is associated with liver and germ cell tumors, and carcinoembryonic antigen (CEA) is linked to colorectal cancer.

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