Nursing Elites

1. A client is being taught how to perform self-catheterization. Which of the following instructions should the nurse include?

• A. Clean the catheter with alcohol after each use.
• B. Perform self-catheterization while sitting on the toilet.
• C. Use a new catheter each time you perform self-catheterization.
• D. Lubricate the catheter tip with petroleum jelly before insertion.

Correct answer: C

Rationale: The correct answer is C: 'Use a new catheter each time you perform self-catheterization.' It is essential to use a new, sterile catheter each time to prevent infection during the procedure. Choice A is incorrect because cleaning the catheter with alcohol may not be sufficient to prevent infection. Choice B is incorrect because self-catheterization is typically done in a clean, private area, not necessarily on the toilet. Choice D is incorrect because lubricating the catheter tip with petroleum jelly is a common practice but not as crucial as using a new catheter each time to prevent infection.

2. A healthcare professional is reviewing the laboratory values of a client who has cirrhosis. Which of the following findings should the healthcare professional report to the provider?

• A. Ammonia 75 mcg/dL
• B. Sodium 142 mEq/L
• C. Calcium 9.5 mg/dL
• D. Bilirubin 2.5 mg/dL

Correct answer: D

Rationale: An elevated bilirubin level in clients with cirrhosis indicates worsening liver function and potential complications. It is crucial to report this finding promptly as it may require immediate medical intervention. Elevated ammonia levels (choice A) are also concerning in cirrhosis, indicating hepatic encephalopathy, but bilirubin levels are more specific to liver function in this context. Choices B and C are within normal ranges and are not typically of immediate concern in cirrhosis.

3. A healthcare professional is reviewing a client's admission laboratory results. Which of the following findings requires further evaluation?

• A. Sodium 138
• B. Creatinine 1.8
• C. Hemoglobin 15
• D. Potassium 4.2

Correct answer: B

Rationale: The correct answer is B. An elevated creatinine level, such as 1.8, suggests potential kidney dysfunction, requiring further assessment. Sodium level within normal limits (135-145 mEq/L), hemoglobin level of 15 g/dL, and potassium level of 4.2 mEq/L are all within normal ranges and do not indicate immediate concerns. Therefore, they do not require further evaluation at this time.

4. A nurse is performing a gastric lavage for a client who has upper gastrointestinal bleeding. Which of the following actions should the nurse take?

• A. Instill 500 ml of solution through the NG tube
• B. Insert a large-bore NG tube
• C. Use a cold irrigation solution
• D. Instruct the client to lie on his right side

Correct answer: B

Rationale: The correct answer is B: 'Insert a large-bore NG tube.' When performing a gastric lavage for a client with upper gastrointestinal bleeding, a large-bore NG tube is used to effectively remove gastric contents and blood. Option A is incorrect because the amount of solution to instill depends on the specific situation and should be guided by the healthcare provider's order. Option C is incorrect because using a cold irrigation solution can lead to hypothermia and is not recommended. Option D is incorrect as there is no need to instruct the client to lie on his right side specifically for gastric lavage.

5. A nurse is performing a dressing change for a client who has a sacral wound using negative pressure wound therapy. Which of the following actions should the nurse take first?

• A. Apply skin preparation to wound edges.
• B. Don sterile gloves.
• C. Normal saline
• D. Determine pain level.

Correct answer: D

Rationale: The correct answer is to determine the pain level first. Assessing the client's pain is crucial before any procedure to ensure their comfort and safety. Applying skin preparation to wound edges (Choice A) may come later in the process after ensuring the client's comfort. Donning sterile gloves (Choice B) is important before directly handling the wound but can follow pain assessment. Normal saline (Choice C) might be used during wound cleansing but is not the initial step in this situation.

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