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. Which of the following procedures always requires surgical asepsis?

• A. Vaginal instillation of conjugated estrogen
• B. Urinary catheterization
• C. Nasogastric tube insertion
• D. Colostomy irrigation

Correct answer: B

Rationale: Surgical asepsis, which involves maintaining a sterile field and preventing contamination in a surgical setting, is required for urinary catheterization as it involves entering a sterile body cavity. Vaginal instillation of conjugated estrogen, nasogastric tube insertion, and colostomy irrigation do not always require surgical asepsis as they involve different levels of sterility and infection control measures.

3. What is another name for the knee-chest position?

• A. Genu-dorsal
• B. Genu-pectoral
• C. Lithotomy
• D. Sim’s

Correct answer: B

Rationale: The knee-chest position is correctly identified as the genu-pectoral position. In this position, a person rests on their knees and chest with the abdomen raised and the head turned to one side. This position is commonly used in medical examinations and procedures involving the rectal or pelvic areas, allowing for better visualization and access. Choice A, 'Genu-dorsal,' is incorrect as it does not refer to the knee-chest position. Choice C, 'Lithotomy,' is incorrect as it refers to a position where the patient is lying on their back with legs flexed and feet in stirrups, commonly used during childbirth or certain surgeries. Choice D, 'Sim’s,' is incorrect as it refers to a position where the patient lies on their left side with the right knee and thigh drawn up with the left arm placed along the back.

4. A client experiencing dyspnea will receive continuous oxygen. Which oxygen device should be used to deliver a precise amount of oxygen?

• A. Non-rebreather mask
• B. Venturi mask
• C. Nasal cannula
• D. Simple face mask

Correct answer: B

Rationale: A Venturi mask is the most appropriate choice for delivering a precise amount of oxygen to a client with dyspnea. Unlike other oxygen delivery devices, the Venturi mask allows for accurate oxygen concentration delivery by controlling the amount of air entrained. This feature is crucial in ensuring the client receives the prescribed oxygen concentration, especially in cases where precise oxygen delivery is required.

5. What is the term for the body's ability to defend itself against specific invading agents such as bacteria, toxins, viruses, and foreign bodies?

• A. Hormones
• B. Secretion
• C. Immunity
• D. Glands

Correct answer: C

Rationale: The correct answer is C: Immunity. Immunity refers to the body's ability to protect itself against specific invading agents like bacteria, toxins, viruses, and foreign bodies by recognizing and destroying them. It is a crucial defense mechanism that helps maintain health and prevent infections and diseases. Choices A, B, and D are incorrect because hormones are chemical messengers, secretion is the process of releasing substances, and glands are organs that produce and release substances, none of which specifically relate to the body's defense against invading agents.

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