Nursing Elites

1. An elderly client seems confused and reports the onset of nausea, dysuria, and urgency with incontinence. Which action should the nurse implement?

• A. Auscultate for renal bruits
• B. Obtain a clean catch mid-stream specimen
• C. Use a dipstick to measure for urinary ketones
• D. Begin to strain the client's urine

Correct answer: B

Rationale: This elderly client is presenting symptoms consistent with a urinary tract infection (UTI), such as confusion, nausea, dysuria, urgency, and incontinence. The best course of action for the nurse is to obtain a clean catch mid-stream specimen. This specimen will help identify the causative agent of the UTI, allowing for targeted treatment with an appropriate anti-infective agent. Auscultating for renal bruits (Choice A) is not indicated in this scenario as the client's symptoms point towards a UTI rather than a renal issue. Using a dipstick to measure for urinary ketones (Choice C) is not relevant in the context of UTI symptoms. Beginning to strain the client's urine (Choice D) would not address the need to identify the causative agent for targeted treatment.

2. Which assessment finding indicates to the nurse a client's readiness for pulmonary function tests?

• A. Expresses an understanding of the procedure.
• B. NPO for 6 hrs.
• C. No known drug allergies.
• D. Intravenous access intact.

Correct answer: A

Rationale: The correct answer is A: 'Expresses an understanding of the procedure.' This choice indicates that the client is mentally prepared for the pulmonary function tests, as understanding the procedure shows readiness and cooperation. Choices B, C, and D are incorrect. Choice B, 'NPO for 6 hrs,' pertains to fasting status and is not directly related to readiness for the test. Choice C, 'No known drug allergies,' is important information but does not specifically indicate readiness for pulmonary function tests. Choice D, 'Intravenous access intact,' is related to vascular access and not a direct indicator of readiness for the pulmonary function tests.

3. A nurse is caring for a client with an indwelling urinary catheter. Which intervention is most important to include in the client's plan of care?

• A. Ensure the catheter is below the level of the bladder at all times.
• B. Change the catheter bag every 48 hours.
• C. Cleanse the perineal area daily.
• D. Perform catheter care daily.

Correct answer: A

Rationale: The correct answer is to ensure the catheter is always below the level of the bladder. Placing the catheter tubing above the level of the bladder can lead to backflow of urine, causing urinary tract infections. Changing the catheter bag every 48 hours is important but not as crucial as maintaining proper catheter positioning. Cleaning the perineal area daily and performing catheter care are essential tasks but do not directly address the prevention of complications associated with catheter placement.

4. The nurse needs to add a medication to a liter of 5% Dextrose in Water (D5W) that is already infusing into a client. At what location should the nurse inject the medication?

• A. Medication port
• B. IV drip chamber
• C. Y-site connector
• D. At the hub of the IV catheter

Correct answer: A

Rationale: The correct answer is the medication port. When adding medication to an already infusing IV solution, it should be done through the medication port to ensure direct delivery into the bloodstream without interrupting the primary IV line. Injecting the medication into the IV drip chamber, Y-site connector, or at the hub of the IV catheter can lead to dilution, inaccurate dosing, or potential blockages in the IV line, which can compromise the effectiveness of the medication and patient safety.

5. After multiple attempts to stop drinking, an adult male is admitted to the medical intensive care unit (MICU) with delirium tremens. He is tachycardic, diaphoretic, restless, and disoriented. Which finding indicates a life-threatening condition?

• A. Widening QRS complexes and flat T waves
• B. Tachycardia and elevated blood pressure
• C. Restlessness and anxiety
• D. Diaphoresis and dehydration

Correct answer: A

Rationale: The correct answer is A: Widening QRS complexes and flat T waves. In the context of an adult male with delirium tremens and symptoms like tachycardia, diaphoresis, restlessness, and disorientation, the presence of widening QRS complexes and flat T waves on an ECG suggests severe electrolyte imbalance, particularly hypokalemia. This severe electrolyte imbalance can lead to life-threatening arrhythmias such as ventricular tachycardia or fibrillation. Tachycardia and elevated blood pressure (choice B) can be expected in delirium tremens but do not directly indicate a life-threatening condition as widening QRS complexes and flat T waves do. Restlessness and anxiety (choice C) are common symptoms of delirium tremens but do not specifically signify a life-threatening condition. Diaphoresis and dehydration (choice D) are also common in delirium tremens but do not directly point towards a life-threatening electrolyte imbalance as widening QRS complexes and flat T waves do.

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