Nursing Elites

1. A client is being prepared for transfer to the operating room. Which of the following actions should the nurse take in the care of this client at this time?

• A. Ensuring that the client has voided
• B. Administering all daily medications
• C. Practicing postoperative breathing exercises
• D. Verifying that the client has not eaten for the last 24 hours

Correct answer: A

Rationale: The nurse should ensure that the client has voided, especially if a Foley catheter is not in place. This step is important to prevent urinary retention during the surgical procedure. Administering all daily medications just before surgery is not standard practice. The physician typically provides specific orders regarding which medications can be taken with a sip of water before surgery. Postoperative breathing exercises are usually taught after surgery to prevent complications like atelectasis. Verifying that the client has not eaten for the last 24 hours is not a standard preoperative practice; instead, the client is usually instructed to fast for a specific period before surgery to reduce the risk of aspiration during anesthesia.

2. The patient will take a high dose of azithromycin after discharge from the hospital. Which statement by the patient indicates understanding of the teaching?

• A. I may take antacids 2 hours before taking this drug.
• B. I should take acetaminophen for fever or mild pain.
• C. I should expect diarrhea to be a common, mild side effect.
• D. I should avoid dairy products while taking this drug.

Correct answer: A

Rationale: The correct answer is A. Azithromycin peak levels may be reduced by antacids when taken at the same time, so patients should be cautioned to take antacids 2 hours before or 2 hours after taking the drug. Choice B is incorrect because high-dose azithromycin carries a risk for hepatotoxicity when taken with other potentially hepatotoxic drugs such as acetaminophen. Choice C is incorrect as diarrhea may indicate pseudomembranous colitis and should be reported, not expected as a common mild side effect. Choice D is incorrect; there is no restriction for dairy products while taking azithromycin.

3. A nurse obtains a sterile urine specimen from a client’s Foley catheter. After applying a clamp to the drainage tubing distal to the injection port, which action should the nurse take next?

• A. Clamp another section of the tube to create a fixed sample section for retrieval.
• B. Insert a syringe into the injection port and aspirate the quantity of urine required.
• C. Clean the injection port cap of the drainage tubing with a povidone-iodine solution.
• D. Withdraw 10 mL of urine and discard it; then withdraw a fresh sample of urine.

Correct answer: C

Rationale: The correct next action for the nurse to take after applying a clamp to the drainage tubing distal to the injection port is to clean the injection port cap of the catheter drainage tubing with an appropriate antiseptic like povidone-iodine solution or alcohol. This step is crucial to prevent surface contamination before taking the urine sample. Clamping another section of the tube to create a fixed sample section or withdrawing and discarding urine are unnecessary and could lead to potential contamination. Inserting a syringe into the injection port and aspirating the required amount of urine directly from the catheter is the correct method for obtaining the urine sample, but cleaning the injection port cap should precede this step to ensure sterility.

4. The healthcare provider assesses a client with cirrhosis and finds 4+ pitting edema of the feet and legs, and massive ascites. Which mechanism contributes to edema and ascites in clients with cirrhosis?

• A. Hyperaldosteronism causing increased sodium transport ion in renal tubules
• B. Decreased portacaval pressure with greater collateral circulation
• C. Decreased renin-angiotensin response related to increased renal blood flow
• D. Hypoalbuminemia that results in decreased colloidal oncotic pressure

Correct answer: D

Rationale: In clients with cirrhosis, hypoalbuminemia leads to decreased colloidal oncotic pressure. This reduction in oncotic pressure contributes to the development of edema in the feet and legs (pitting edema) and ascites in the abdomen. Hyperaldosteronism (choice A) would lead to sodium retention but is not the primary mechanism behind edema and ascites in cirrhosis. Decreased portacaval pressure with greater collateral circulation (choice B) is not directly related to the pathophysiology of edema and ascites in cirrhosis. Decreased renin-angiotensin response related to increased renal blood flow (choice C) does not play a significant role in the development of edema and ascites in cirrhosis compared to the impact of hypoalbuminemia on colloidal oncotic pressure.

5. A nurse reviews laboratory results for a client with glomerulonephritis. The client’s glomerular filtration rate (GFR) is 40 mL/min as measured by a 24-hour creatinine clearance. How should the nurse interpret this finding? (Select all that apply.)

• A. Excessive GFR
• B. Reduced GFR
• C. Fluid retention and risks for hypertension
• D. Pulmonary edema

Correct answer: B

Rationale: A GFR of 40 mL/min indicates a reduced glomerular filtration rate. In a healthy adult, the normal GFR ranges between 100 and 120 mL/min. A GFR of 40 mL/min signifies a significant reduction, leading to fluid retention and risks for hypertension and pulmonary edema due to excess vascular fluid. Choices A, C, and D are incorrect. Choice A is incorrect as a GFR of 40 mL/min is not excessive but rather reduced. Choices C and D do not directly address the interpretation of GFR but instead describe potential consequences of a reduced GFR.

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