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. The nurse is instructing a client with high cholesterol about diet and life style modification. What comment from the client indicates that the teaching has been effective?

• A. If I exercise at least two times weekly for one hour, I will lower my cholesterol.
• B. I need to avoid eating proteins, including red meat.
• C. I will limit my intake of beef to 4 ounces per week.
• D. My blood level of low density lipoproteins needs to increase.

Correct answer: C

Rationale: Limiting saturated fat from animal food sources to no more than 4 ounces per week is an important diet modification for lowering cholesterol. To be effective in reducing cholesterol, the client should exercise 30 minutes per day, or at least 4 to 6 times per week. Red meat and all proteins do not need to be eliminated to lower cholesterol, but should be restricted to lean cuts of red meat and smaller portions. The low density lipoproteins need to decrease rather than increase.

3. A client is diagnosed with primary hypertension. Which assessment finding is most commonly associated with this diagnosis?

• A. Headache
• B. Dizziness
• C. Fatigue
• D. Edema

Correct answer: A

Rationale: Headache (A) is the most commonly associated symptom with primary hypertension due to increased pressure in the blood vessels, leading to headaches. While dizziness (B), fatigue (C), and edema (D) may also occur in hypertension, headache is the most frequently reported symptom among individuals with primary hypertension.

4. The healthcare provider attaches a pulse oximeter to a client's fingers and obtains an oxygen saturation reading of 91%. Which assessment finding most likely contributes to this reading?

• A. BP 142/88 mmHg
• B. 2+ edema of fingers and hands
• C. Radial pulse volume is +3
• D. Capillary refill time is 2 seconds

Correct answer: B

Rationale: Edema in the fingers and hands can impede the proper functioning of the pulse oximeter, leading to a falsely low oxygen saturation reading. Edema alters the transmission of light through the tissues, affecting the accuracy of the measurement. Therefore, the presence of edema in the fingers and hands is the most likely factor contributing to the low oxygen saturation reading of 91%.

5. A male client with unstable angina needs a cardiac catheterization. The healthcare provider explains the risks and benefits of the procedure and then leaves to set up for the procedure. When the nurse presents the consent form for signature, the client hesitates and asks how the wires will keep his heart going. Which action should the nurse take?

• A. Answer the client’s specific questions with a short, understandable explanation
• B. Postpone the procedure until the client understands the risks and benefits
• C. Call the client’s next of kin and ask them to provide verbal consent
• D. Page the healthcare provider to return and provide additional explanation

Correct answer: D

Rationale: The nurse should ask the healthcare provider to return and provide further explanation to the client. The healthcare provider is the one who can address the risks and benefits of the procedure in detail, ensuring the client receives accurate information before providing consent.

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