Nursing Elites

1. A nurse is preparing to insert an indwelling urinary catheter in a female client. Which action should the nurse take to maintain sterile technique?

• A. Apply sterile gloves before inserting the catheter
• B. Use sterile gloves to insert the catheter
• C. Clean the urinary meatus with an antiseptic solution
• D. Place the drainage bag above the level of the bladder

Correct answer: B

Rationale: Using sterile gloves to insert the catheter is crucial to maintaining sterile technique. Sterile gloves help prevent the introduction of microorganisms during the insertion process. Applying sterile gloves before cleansing the perineal area (Choice A) is important but not specific to maintaining sterility during catheter insertion. Cleaning the urinary meatus with an antiseptic solution (Choice C) is a step in the catheterization process but does not solely ensure sterile technique. Placing the drainage bag above the level of the bladder (Choice D) is incorrect; the bag should be placed below the level of the bladder to facilitate urine drainage.

2. The nurse is preparing to administer medications to a client with a nasogastric tube. Which action should the nurse take first?

• A. Check for tube placement
• B. Crush the medications
• C. Flush the tube with water
• D. Administer the medications

Correct answer: A

Rationale: The correct first action when administering medications to a client with a nasogastric tube is to check for tube placement. This is crucial to ensure that the medications are delivered to the correct location within the gastrointestinal tract. Checking the tube placement helps prevent complications such as medication entering the lungs if the tube is misplaced. Crushing the medications (choice B) or flushing the tube with water (choice C) should only be done after confirming the correct tube placement. Administering the medications (choice D) without verifying the tube placement can lead to serious consequences.

3. When caring for a laboring client whose contractions are occurring every 2-3 minutes, the nurse should document that the pump is infusing how many ml/hour?

• A. 5
• B. 10
• C. 15
• D. 20

Correct answer: A

Rationale: The correct calculation for infusion based on the given data is 5 ml/hr. To calculate the infusion rate per hour, you need to determine the number of contractions per hour. If contractions are occurring every 2-3 minutes, this would mean approximately 20-30 contractions per hour. Therefore, if the pump is infusing 5 ml per contraction, the total infusion rate per hour would be 5 ml x 20 contractions = 100 ml/hr. This makes choice A the correct answer. Choices B, C, and D are incorrect as they do not align with the calculation based on the given data.

4. Is it necessary to continue to strain the urine of a client with kidney stones since several stones were obtained the previous day?

• A. UAPs should follow the prescribed care without questioning it
• B. Yes, it is important to continue straining all the client's urine
• C. Measuring intake and output is equally important as straining the urine
• D. Ensuring that the client is free from pain should be the top priority

Correct answer: B

Rationale: Yes, it is important to continue straining all urine to catch any remaining stones. Straining the urine helps in identifying any new stones that may have formed, allowing for appropriate management. While measuring intake and output is important, straining the urine is specifically necessary in this case to monitor the presence of kidney stones. Ensuring the client is free from pain is essential, but in this situation, preventing further complications related to kidney stones is a higher priority.

5. The nurse is administering total parenteral nutrition (TPN) via a central line at 75 ml/hour to a client who had a bowel resection 4 days ago. Which laboratory finding requires the most immediate intervention by the nurse?

• A. Blood glucose of 140 mg/dL
• B. White blood cell count of 8000/mm³
• C. Serum potassium of 3.8 mEq/L
• D. Serum calcium of 7.8 mg/dL

Correct answer: D

Rationale: The correct answer is D. A serum calcium level of 7.8 mg/dL requires immediate intervention due to the risk of hypocalcemia. Hypocalcemia can lead to serious complications such as tetany, seizures, and cardiac arrhythmias. The other laboratory findings are within normal limits or slightly elevated, which do not pose an immediate threat to the client's health in this scenario.

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