Nursing Elites

1. A client arrived to the medical-surgical unit 4 hours after a transurethral resection of the prostate (TURP). A triple-lumen catheter for continuous bladder irrigation with normal saline is infusing, and the nurse observes dark, pink-tinged outflow with blood clots in the tubing and collection bag. Which action should the nurse take?

• A. Monitoring catheter drainage
• B. Decreasing the flow rate
• C. Irrigating the catheter manually
• D. Discontinuing infusing the solution

Correct answer: C

Rationale: In this scenario, the nurse should choose option C - irrigating the catheter manually. This action can help clear the clots from the catheter and ensure proper bladder drainage. Monitoring catheter drainage (option A) alone may not address the issue of clots obstructing the flow. Decreasing the flow rate (option B) could potentially worsen clot formation. Discontinuing the infusing solution (option D) without addressing the clots first may lead to inadequate irrigation and increase the risk of complications.

2. A client who has just undergone bronchoscopy was returned to the nursing unit 1 hour ago. With which assessment finding is the nurse most concerned?

• A. Oxygen saturation of 97%
• B. Equal breath sounds in both lungs
• C. Absence of cough and gag reflexes
• D. Respiratory rate of 20 breaths/min

Correct answer: C

Rationale: The correct answer is C. The absence of cough and gag reflexes is the most concerning finding for the nurse because it indicates a lack of protective airway reflexes, putting the client at risk of aspiration. Oxygen saturation of 97% is within the normal range and indicates adequate oxygenation. Equal breath sounds in both lungs are a positive finding, indicating no significant abnormalities. A respiratory rate of 20 breaths/min is also within the normal range and does not raise immediate concerns. Therefore, the absence of cough and gag reflexes poses the highest risk to the client's airway safety.

3. An emergency department nurse assesses a client with kidney trauma and notes that the client’s abdomen is tender and distended, and blood is visible at the urinary meatus. Which prescription should the nurse consult the provider about before implementation?

• A. Assessing vital signs every 15 minutes
• B. Inserting an indwelling urinary catheter
• C. Administering intravenous fluids at 125 mL/hr
• D. Typing and crossmatching for blood products

Correct answer: B

Rationale: In a client with kidney trauma and blood visible at the urinary meatus, inserting a urinary catheter via the urethra should be avoided until further diagnostic studies are completed to prevent potential urethral tears. The nurse should consult the provider about the need for a catheter; if necessary, a suprapubic catheter can be used instead. Assessing vital signs every 15 minutes is important for continuous monitoring of the client's condition. Administering intravenous fluids at 125 mL/hr is crucial to maintain hydration and support kidney function. Typing and crossmatching for blood products is necessary in case the client requires blood transfusion due to potential blood loss from the trauma.

4. The client with chronic renal failure who is on a low-sodium diet should avoid which of the following foods?

• A. Fresh fruits.
• B. Canned soups.
• C. Lean meats.
• D. Whole grain bread.

Correct answer: B

Rationale: Canned soups are high in sodium, which can lead to fluid retention and hypertension in clients with chronic renal failure who are on a low-sodium diet. Fresh fruits, lean meats, and whole grain bread are generally lower in sodium and can be included in a low-sodium diet. Lean meats provide essential protein, fresh fruits offer vitamins and minerals, and whole grain bread provides fiber, making them suitable choices for individuals with chronic renal failure.

5. A nurse cares for clients with urinary incontinence. Which types of incontinence are correctly paired with their clinical manifestations? (Select all that apply.)

• A. Stress incontinence – Urine loss with physical exertion
• B. Urge incontinence – Large amount of urine with each occurrence
• C. Overflow incontinence – Constant dribbling of urine
• D. All of the above

Correct answer: D

Rationale: The correct answer is D, as all the choices are correctly paired with their clinical manifestations. Stress incontinence is characterized by urine loss with physical exertion, coughing, sneezing, or exercising. Urge incontinence presents with a sudden and strong urge to void, often accompanied by a large amount of urine released during each occurrence. Overflow incontinence occurs when the bladder is distended, leading to a constant dribbling of urine. Functional incontinence, not mentioned in the options, is the leakage of urine due to factors unrelated to a lower urinary tract disorder. Reflex incontinence, also not mentioned, is a condition resulting from abnormal detrusor contractions.

Similar Questions