Nursing Elites

1. A nurse reviews a client’s urinalysis report. Which finding does the nurse recognize as abnormal?

• A. pH of 6.0
• B. An absence of protein
• C. The presence of ketones
• D. Specific gravity of 1.018

Correct answer: C

Rationale: The correct answer is C. The presence of ketones in the urine is abnormal. Ketones in the urine may indicate a state of ketosis, which is commonly seen in uncontrolled diabetes, fasting, or a low-carbohydrate diet. A normal pH range of urine is 4.5 to 7.8, making a pH of 6.0 within the normal range. An absence of protein is a normal finding in urine, as proteinuria (presence of protein) is abnormal. A specific gravity of 1.018 falls within the normal range of 1.016 to 1.022. Therefore, the presence of ketones is the abnormal finding in this scenario.

2. A client admitted from a nursing home after several recent falls needs a urine sample for culture and sensitivity. What should the nurse complete first?

• A. Obtain urine sample for culture and sensitivity.
• B. Administer intravenous antibiotics.
• C. Encourage protein intake and additional fluids.
• D. Consult physical therapy for gait training.

Correct answer: A

Rationale: In this scenario, the priority intervention is to obtain a urine sample for culture and sensitivity. Older adults with recent falls may have atypical symptoms of urinary tract infection (UTI), which can present as new-onset confusion or falling. It is crucial to rule out UTI before initiating antibiotics. While administering antibiotics, encouraging protein intake, fluids, and consulting physical therapy are important interventions, they should follow the urine sample collection to ensure accurate diagnosis and appropriate treatment.

3. A female client is brought to the clinic by her daughter for a flu shot. She has lost significant weight since the last visit. She has poor personal hygiene and inadequate clothing for the weather. The client states that she lives alone and denies problems or concerns. What action should the nurse implement?

• A. Notify social services immediately if suspected elderly abuse is present.
• B. Discuss the need for mental health counseling with the daughter.
• C. Explain to the client the importance of taking better care of herself.
• D. Collect further data to determine whether self-neglect is occurring.

Correct answer: D

Rationale: In this scenario, the client presents with significant weight loss, poor hygiene, and inadequate clothing, which are concerning signs of self-neglect. Before taking action, it is crucial for the nurse to collect more data to determine the root cause of these issues. Jumping to conclusions or immediately involving social services without a thorough assessment could potentially harm the client or strain relationships. Discussing the need for mental health counseling with the daughter or simply advising the client to take better care of herself may not address the underlying problem of self-neglect. Therefore, the most appropriate initial action is for the nurse to collect further data to make an informed decision before taking the next steps.

4. The nurse is caring for a client who is receiving an IV infusion of normal saline and notices that the infusion is not flowing. The insertion site is not inflamed or swollen. What should the nurse do first?

• A. Check the tubing for kinks or obstructions.
• B. Increase the flow rate to improve the infusion.
• C. Reinsert the IV catheter in another vein.
• D. Call the physician for further instructions.

Correct answer: A

Rationale: The correct first action for the nurse to take when an IV infusion is not flowing despite a normal insertion site is to check the tubing for kinks or obstructions. This step is crucial to ensure that there are no preventable issues impeding the flow of the IV solution. Increasing the flow rate without addressing potential obstructions could lead to complications such as infiltration. Reinserting the IV catheter in another vein should only be considered after ruling out tubing issues. Calling the physician for further instructions is not necessary at this stage as troubleshooting the tubing should be the initial intervention.

5. A client who has just undergone a skin biopsy is listening to discharge instructions from the nurse. The nurse determines that the client has misunderstood the directions if the client indicates that as part of aftercare he plans to:

• A. Use the antibiotic ointment as prescribed
• B. Return in 7 days to have the sutures removed
• C. Apply cool compresses to the site twice a day for 20 minutes
• D. Call the physician if excessive drainage from the wound occurs

Correct answer: C

Rationale: The correct answer is C. Applying cool compresses to the site twice a day for 20 minutes is not a recommended aftercare practice for a skin biopsy. After a skin biopsy, it is important to keep the dressing dry and in place for a minimum of 8 hours. Choice A is correct as using the antibiotic ointment as prescribed is a common post-biopsy instruction to prevent infection. Choice B is also correct as returning in 7 days to have the sutures removed is part of the typical follow-up care after a skin biopsy. Choice D is correct as it is important to call the physician if excessive drainage from the wound occurs to prevent complications.

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