Nursing Elites

1. When emptying 350 mL of pale yellow urine from a client's urinal, the nurse notes that this is the first time the client has voided in 4 hours. Which action should the nurse take next?

• A. Record the amount on the client's fluid output record.
• B. Encourage the client to increase oral fluid intake.
• C. Notify the healthcare provider of the findings.
• D. Palpate the client's bladder for distention.

Correct answer: A

Rationale: The nurse should record the amount on the client's fluid output record because the 350 mL of pale yellow urine is a normal finding. This indicates appropriate urine output, so encouraging increased fluid intake or notifying the healthcare provider is not necessary at this time. Additionally, palpating the client's bladder for distention is not indicated based on the normal urine output observed.

2. The client is receiving discharge teaching for a new diagnosis of asthma. Which statement by the client indicates a need for further teaching?

• A. I should use my inhaler as soon as I begin to feel short of breath.
• B. I should avoid using my inhaler unless I am having an asthma attack.
• C. I should use my inhaler 30 minutes before exercise.
• D. I should rinse my mouth after using my inhaler.

Correct answer: B

Rationale: The statement 'I should avoid using my inhaler unless I am having an asthma attack' (B) indicates a need for further teaching. It is important for clients to use their inhaler as prescribed, which may include regular use to prevent asthma attacks. Choice A is correct because using the inhaler when feeling short of breath can help manage asthma symptoms. Choice C is also correct as using the inhaler before exercise can prevent exercise-induced symptoms. Choice D is correct as rinsing the mouth after using the inhaler helps prevent oral thrush, a potential side effect of inhaled corticosteroids. Therefore, option B is the most concerning statement that needs clarification.

3. What is the most important action for the nurse to take when caring for a client with a spinal cord injury experiencing autonomic dysreflexia?

• A. Elevate the head of the bed to 45 degrees.
• B. Monitor the client's respiratory rate.
• C. Administer an antihypertensive medication.
• D. Assess the client's blood glucose level.

Correct answer: A

Rationale: In a client with autonomic dysreflexia, the most critical action is to elevate the head of the bed to 45 degrees (A). This positioning helps reduce blood pressure, which is essential in managing autonomic dysreflexia. Monitoring the client's respiratory rate (B) is important for overall assessment but not the priority in this situation. Administering an antihypertensive medication (C) without addressing the positioning issue first can lead to further complications. Assessing the client's blood glucose level (D) is not directly related to autonomic dysreflexia and is not the initial priority in this scenario.

4. After hemodialysis, a client with a history of chronic renal failure has just returned to the unit. What is the most important assessment for the nurse to make?

• A. Auscultate the client's lung sounds.
• B. Assess the client's blood pressure.
• C. Monitor the client's weight.
• D. Check the client's fistula for bruit and thrill.

Correct answer: D

Rationale: The most crucial assessment for the nurse to make after hemodialysis in a client with chronic renal failure is to check the client's fistula for bruit and thrill (D). This assessment is essential to ensure the patency of the fistula and adequate blood flow. Auscultating lung sounds (A), assessing blood pressure (B), and monitoring weight (C) are important assessments but are secondary to evaluating the fistula. Checking the fistula is vital as it directly impacts the effectiveness of the client's dialysis treatment and the patency of the vascular access, ensuring successful dialysis sessions.

5. The healthcare provider is providing passive range of motion (ROM) exercises to the hip and knee for a client who is unconscious. After supporting the client's knee with one hand, what action should the healthcare provider take next?

• A. Raise the bed to a comfortable working level.
• B. Bend the client's knee.
• C. Move the knee toward the chest as far as it will go.
• D. Cradle the client's heel.

Correct answer: D

Rationale: When providing passive ROM exercises to the hip and knee for an unconscious client, it is essential to support the joints of the knee and ankle. The next action should be to cradle the client's heel and gently move the limb in a slow, smooth, firm, but gentle manner. This helps maintain joint mobility and prevent contractures.

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