Nursing Elites

1. To assess the kidney function of a patient with an indwelling urinary (Foley) catheter, the nurse measures the hourly urine output. When should she notify the physician?

• A. Less than 30 ml/hour
• B. 64 ml in 2 hours
• C. 90 ml in 3 hours
• D. 125 ml in 4 hours

Correct answer: A

Rationale: Notifying the physician is necessary when the urine output is less than 30 ml/hour as it indicates impaired kidney function. Adequate urine output is essential for monitoring kidney function, and a urine output less than 30 ml/hour could suggest potential renal issues that require medical attention.

2. A healthcare professional is planning care for a client following the insertion of a chest tube and drainage system. Which of the following should NOT be included in the plan of care?

• A. Encourage the client to cough every 2 hours.
• B. Check for continuous bubbling in the suction chamber.
• C. Strip the drainage tubing every 4 hours.
• D. Obtain a chest x-ray

Correct answer: C

Rationale: Stripping the drainage tubing is an outdated practice and can cause complications. Encouraging the client to cough helps with lung expansion, checking for continuous bubbling ensures proper functioning of the chest tube system, and obtaining a chest x-ray helps to assess the position of the chest tube and re-expansion of the lung. Therefore, stripping the drainage tubing every 4 hours should not be included in the plan of care.

3. Which of the following patients is at greater risk for contracting an infection?

• A. A patient with leukopenia
• B. A patient receiving broad-spectrum antibiotics
• C. A postoperative patient who has undergone orthopedic surgery
• D. A newly diagnosed diabetic patient

Correct answer: A

Rationale: Leukopenia, characterized by low white blood cell count, significantly reduces the body's ability to fight infections. Patients with leukopenia are at a higher risk of contracting infections due to compromised immune defenses.

4. A client experiencing acute dyspnea and diaphoresis reports anxiety and difficulty breathing. Vital signs include HR 117/min, respirations 38/min, temperature 38.4 C (101.2 F), and blood pressure 100/54 mm Hg. What should the nurse prioritize?

• A. Notify the provider.
• B. Administer heparin via IV infusion.
• C. Administer oxygen therapy.
• D. Obtain a spiral CT scan.

Correct answer: C

Rationale: In a client with acute dyspnea, diaphoresis, tachycardia, tachypnea, fever, and hypotension, the priority is to ensure adequate oxygenation. Administering oxygen therapy helps improve oxygenation levels and stabilize the client's condition. This intervention takes precedence over notifying the provider, administering heparin, or obtaining a CT scan, as oxygen therapy addresses the client's immediate need for respiratory support.

5. A healthcare professional is receiving a telephone prescription from a provider for a client who requires additional medication for pain control. Which of the following entries should the healthcare professional make in the medical record?

• A. Morphine 3 mg Subcutaneous every 4 hr. PRN for pain.
• B. Morphine 3 mg Subcutaneous
• C. Morphine 3.0 mg subcutaneously every 4 hr. PRN for pain.
• D. Morphine 3 mg Subcutaneous q 4 hr. PRN for pain.

Correct answer: D

Rationale: The correct entry for documenting the prescription for morphine is 'Morphine 3 mg Subcutaneous'. This entry accurately specifies the medication, dosage, route of administration, and frequency as prescribed by the provider. Options A, C, and D contain minor errors such as missing units of measurement or incorrect abbreviations, which could lead to misinterpretation or potential medication errors. Therefore, the most appropriate and accurate choice is 'Morphine 3 mg Subcutaneous'.

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