Nursing Elites

1. A nurse is preparing to perform closed intermittent bladder irrigation for a client following a transurethral resection of the prostate (TURP). Which of the following actions is appropriate by the nurse?

• A. Aspirate the irrigation solution from the bladder
• B. Insert the tip of the irrigation syringe into the catheter opening
• C. Apply sterile gloves
• D. Open the flow clamp to the irrigating fluid infusion tubing

Correct answer: C

Rationale: The correct action for the nurse to take before performing a closed intermittent bladder irrigation is to apply sterile gloves. Sterile gloves help maintain asepsis, reduce the risk of infection, and ensure patient safety during the procedure. Aspirating the irrigation solution from the bladder (Choice A) is not a standard step in closed intermittent bladder irrigation. Inserting the tip of the irrigation syringe into the catheter opening (Choice B) can introduce contaminants into the system. Opening the flow clamp to the irrigating fluid infusion tubing (Choice D) should only be done after ensuring all equipment is ready and the nurse is gloved to maintain sterility.

2. A nurse is planning care for a client who has a new diagnosis of deep vein thrombosis (DVT). Which action should the nurse take?

• A. Massage the affected extremity
• B. Elevate the affected leg
• C. Apply cold packs to the affected leg
• D. Keep the leg dependent to increase circulation

Correct answer: B

Rationale: Elevating the leg promotes venous return and reduces swelling, which is crucial for clients with DVT. Massaging the affected extremity can dislodge the clot and worsen the condition. Applying cold packs can cause vasoconstriction, potentially increasing the risk of clot formation. Keeping the leg dependent can impede circulation and increase the risk of clot migration.

3. A nurse is caring for a client who has been taking haloperidol for several years. Which of the following assessment findings should the nurse recognize as a long-term side effect of this medication?

• A. Lip-smacking
• B. Agranulocytosis
• C. Clang association
• D. Alopecia

Correct answer: A

Rationale: Lip-smacking is a symptom of tardive dyskinesia, a long-term side effect of antipsychotic medications like haloperidol, characterized by involuntary movements of the face and jaw. Agranulocytosis (Choice B) is a rare but serious side effect of some medications, characterized by a dangerously low white blood cell count. Clang association (Choice C) is a thought disorder characterized by the association of words based on sound rather than meaning. Alopecia (Choice D) refers to hair loss, which is not a known long-term side effect of haloperidol.

4. A nurse is caring for a client receiving corticosteroids. Which of the following should the nurse monitor?

• A. Blood glucose levels
• B. Blood pressure
• C. Serum potassium levels
• D. Both A and B

Correct answer: D

Rationale: When a client is receiving corticosteroids, the nurse should monitor both blood glucose levels and blood pressure. Corticosteroids can elevate blood glucose levels, leading to hyperglycemia, and may cause hypertension. Monitoring these parameters is essential to detect and address any potential adverse effects promptly. While monitoring serum potassium levels is important in some situations, it is not a primary concern when caring for a client receiving corticosteroids. Therefore, choices A and B are the most appropriate options for monitoring in this scenario, making option D the correct answer.

5. A nurse is assessing a client with chronic kidney disease. Which of the following findings should the nurse monitor?

• A. Hypokalemia
• B. Fluid overload
• C. Decreased blood pressure
• D. Increased appetite

Correct answer: B

Rationale: The correct answer is B: Fluid overload. Clients with chronic kidney disease are prone to fluid overload due to impaired kidney function. The kidneys may not effectively regulate fluid balance, leading to fluid retention. Monitoring for signs of fluid overload, such as edema, hypertension, and shortness of breath, is crucial. Choice A, Hypokalemia, is less likely in chronic kidney disease as the kidneys often have difficulty excreting potassium, leading to hyperkalemia. Decreased blood pressure (Choice C) is not a common finding in chronic kidney disease unless complications like volume depletion occur. Increased appetite (Choice D) is not typically associated with chronic kidney disease; in fact, many clients may experience a decreased appetite due to various factors such as uremia and dietary restrictions.

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