Nursing Elites

1. When using an open irrigation technique to irrigate a client's indwelling urinary catheter, which of the following actions should the nurse take?

• A. Place the client in a side-lying position
• B. Instill 15 mL of irrigation fluid into the catheter with each flush
• C. Subtract the amount of irrigant used from the client's urine output
• D. Perform the irrigation using a 20 mL syringe

Correct answer: C

Rationale: The correct action for the nurse to take when using an open irrigation technique on a client with an indwelling urinary catheter is to subtract the amount of irrigant used from the client's urine output. This calculation helps ensure an accurate measurement of the client's actual urine output by accounting for the irrigation fluid introduced into the catheter. Placing the client in a side-lying position (Choice A) is not directly related to the irrigation procedure. Instilling a specific volume of irrigation fluid (Choice B) may vary depending on the client's condition and the healthcare provider's order. Using a 20 mL syringe for irrigation (Choice D) is a matter of equipment choice and does not directly impact the calculation of urine output in this context.

2. The healthcare provider is providing postoperative care to a client who had a submucosal resection (SMR) for a deviated septum. The healthcare provider should monitor for what complication associated with this type of surgery?

• A. Occipital headache
• B. Periorbital crepitus
• C. Expectoration of blood
• D. Changes in vocalization

Correct answer: C

Rationale: Expectoration of blood is a potential complication following SMR surgery, as it may indicate bleeding postoperatively. In contrast, occipital headache (choice A) is not a common complication associated with SMR surgery. Periorbital crepitus (choice B) is more related to facial fractures or certain infections rather than SMR surgery. Changes in vocalization (choice D) are not typically associated with complications following SMR surgery.

3. A client with a new diagnosis of diabetes mellitus is being taught how to administer insulin. Which of the following instructions should the nurse include?

• A. Administer the insulin in the same body area each time.
• B. Store the insulin according to the manufacturer's instructions.
• C. Rotate injection sites within the same body area.
• D. Inject the insulin at a 45-degree angle.

Correct answer: C

Rationale: The correct instruction the nurse should include is to rotate injection sites within the same body area. This practice helps prevent lipodystrophy, a condition characterized by the thickening or thinning of subcutaneous fat at the injection sites, which can affect insulin absorption. Choice A is incorrect because administering insulin in the same area each time can lead to lipodystrophy. Choice B is incorrect as insulin should be stored according to the manufacturer's instructions, which may include refrigeration. Choice D is incorrect because the angle of insulin injection (usually 90 degrees) is determined by the length of the needle and the amount of subcutaneous fat, not a fixed 45-degree angle.

4. During a neurologic examination, which assessment should a nurse perform to test a client's balance?

• A. Romberg test
• B. Heel-to-toe walk
• C. Snellen test
• D. Spinal accessory function

Correct answer: A

Rationale: The Romberg test is used to assess a client's balance by evaluating their ability to maintain a steady posture with eyes closed. The heel-to-toe walk is another assessment that tests balance by assessing gait and coordination. The Snellen test is used to assess visual acuity and is unrelated to balance. Testing spinal accessory function involves assessing the movement of the head and shoulders and is not directly related to balance assessment.

5. A 3-year-old child diagnosed with celiac disease attends a daycare center. Which of the following would be an appropriate snack?

• A. Cheese crackers
• B. Peanut butter sandwich
• C. Potato chips
• D. Vanilla cookies

Correct answer: C

Rationale: The correct answer is potato chips. As a child with celiac disease needs to avoid gluten, potato chips are a suitable snack choice as they are typically gluten-free. Cheese crackers (Choice A) and vanilla cookies (Choice D) contain gluten, which should be avoided by individuals with celiac disease. While peanut butter sandwiches (Choice B) could be gluten-free depending on the bread used, it is not the best choice as cross-contamination is a concern in shared environments like daycare centers.

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