Nursing Elites

1. What action should the nurse take after applying gloves to irrigate a client's indwelling urinary catheter using an open technique?

• A. Empty the client's urinary drainage bag.
• B. Draw up the irrigating solution into the syringe.
• C. Secure the client's catheter to the drainage tubing.
• D. Use aseptic technique to instill the irrigating solution.

Correct answer: B

Rationale: After applying gloves to irrigate an indwelling urinary catheter using an open technique, the next step for the nurse is to draw up the irrigating solution into the syringe. This step is crucial as it ensures that the solution is ready to be instilled through the catheter to maintain its patency and prevent blockages. Option A is incorrect as emptying the client's urinary drainage bag is not the immediate next step in the irrigation process. Option C is incorrect as securing the client's catheter to the drainage tubing is not necessary at this stage. Option D is incorrect as the question pertains to the action immediately after applying gloves and does not involve instilling the irrigating solution yet.

2. Which client care task requires the nurse to wear barrier gloves as mandated by the Standard Precautions protocol?

• A. Removing the empty food tray from a client with a urinary catheter.
• B. Washing and combing the hair of a client with a fractured leg in traction.
• C. Administering oral medications to a cooperative client with a wound infection.
• D. Emptying the urinary catheter drainage bag for a client with Alzheimer's disease.

Correct answer: D

Rationale: The correct answer is D because emptying a urinary catheter drainage bag exposes the nurse to body fluids, necessitating the use of barrier gloves as per Standard Precautions to prevent potential infection transmission.

3. When assisting an older client who can stand but not ambulate from the bed to a chair, what is the best action for the nurse to implement?

• A. Use a mechanical lift to transfer the client from the bed to a chair.
• B. Place a roller board under the client who is sitting on the side of the bed and slide the client to the chair.
• C. Lift the client out of bed to the chair with another staff member using a coordinated effort on the count of three.
• D. Place a transfer belt around the client, assist the client to stand, and pivot to a chair that is placed at a right angle to the bed.

Correct answer: D

Rationale: The best action for the nurse when assisting an older client who can stand but not ambulate from the bed to a chair is to use a transfer belt. Placing a transfer belt around the client, assisting the client to stand, and pivoting to a chair that is placed at a right angle to the bed allows for a safe and controlled transfer. This method promotes patient independence while ensuring safety during the transfer process. Choices A, B, and C are incorrect because using a mechanical lift may not be necessary for a client who can stand, using a roller board may not provide enough stability, and lifting the client with the help of another staff member may not be the safest option for the client's independence and safety.

4. The client has received a new diagnosis of heart failure, and the nurse is providing dietary management education. Which instruction should the nurse include?

• A. Increase intake of foods high in potassium.
• B. Avoid foods high in sodium.
• C. Limit fluid intake to 1.5 liters per day.
• D. Increase intake of foods high in vitamin K.

Correct answer: B

Rationale: Avoiding foods high in sodium (choice B) is essential for clients with heart failure to prevent fluid retention and decrease the strain on the heart. High sodium intake can lead to fluid buildup, exacerbating heart failure symptoms. Increasing potassium intake (choice A) can be harmful in heart failure if not monitored closely as it can affect heart rhythm. Limiting fluid intake (choice C) may be necessary in some cases, but the specific amount should be individualized based on the client's condition. Increasing vitamin K intake (choice D) is not a primary concern in heart failure management and is more relevant for clients on anticoagulants to manage blood clotting.

5. When taking a client's blood pressure, the healthcare professional is unable to distinguish the point at which the first sound was heard. What is the best action for the healthcare professional to take?

• A. Deflate the cuff completely and immediately reattempt the reading.
• B. Reinflate the cuff completely and leave it inflated for 90 to 110 seconds before taking the second reading.
• C. Deflate the cuff to zero and wait 30 to 60 seconds before reattempting the reading.
• D. Document the exact level visualized on the sphygmomanometer where the first fluctuation was seen.

Correct answer: C

Rationale: The correct action when unable to distinguish the point of the first sound during blood pressure measurement is to deflate the cuff to zero and wait 30 to 60 seconds before reattempting the reading. This allows blood flow to return to the extremity, ensuring a more accurate reading the second time. It is important to ensure that the cuff is fully deflated and the appropriate wait time is given to obtain an accurate blood pressure measurement.

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