Nursing Elites

1. A client is scheduled for a colonoscopy. What instruction should the nurse provide to prepare the client for the procedure?

• A. Drink clear liquids for 24 hours before the procedure
• B. Take a laxative the morning of the procedure
• C. Eat a light meal before the procedure
• D. Avoid drinking fluids for 4 hours before the procedure

Correct answer: A

Rationale: The correct instruction for preparing a client for a colonoscopy is to drink clear liquids for 24 hours before the procedure. This step helps to ensure the bowel is adequately cleared for the colonoscopy, allowing for better visualization and examination of the colon.

2. While suctioning a client’s nasopharynx, the nurse observes that the client’s oxygen saturation remains at 94%, which is the same reading obtained prior to starting the procedure. What action should the nurse take in response to this finding?

• A. Complete the intermittent suction of the nasopharynx.
• B. Reposition the pulse oximeter clip to obtain a new reading.
• C. Stop suctioning until the pulse oximeter reading is above 95%.
• D. Apply an oxygen mask over the client’s nose and mouth.

Correct answer: A

Rationale: A stable oxygen saturation reading of 94% indicates that the nurse can continue with the suctioning procedure. It is within an acceptable range, and there is no immediate need to interrupt the procedure. Continuing with the suctioning will help maintain airway patency and promote adequate oxygenation. Choice B is incorrect because repositioning the pulse oximeter clip is unnecessary when the reading is stable. Choice C is incorrect as there is no evidence to support stopping the suctioning procedure solely based on the oxygen saturation reading of 94%. Choice D is not the best action at this point, as applying an oxygen mask is not indicated when the oxygen saturation is stable and within an acceptable range.

3. 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.

4. The healthcare provider plans to administer diazepam, 4 mg IV push, to a client with severe anxiety. How many milliliters should the healthcare provider administer? (Round to the nearest tenth.)

• A. 0.2 mL
• B. 0.8 mL
• C. 1.25 mL
• D. 2.0 mL

Correct answer: B

Rationale: To calculate the volume to administer, use the formula (1 mL × 4 mg) / 5 mg = 0.8 mL. The healthcare provider should administer 0.8 mL of diazepam for a dosage of 4 mg IV push. Choice A is incorrect because it results from an incorrect calculation. Choices C and D are incorrect as they do not align with the correct calculation based on the provided dosage.

5. A client has an elevated AST 24 hours following chest pain and shortness of breath. This is suggestive of which of the following?

• A. Gallbladder disease
• B. Liver disease
• C. Myocardial infarction
• D. Skeletal muscle injury

Correct answer: C

Rationale: An elevated AST level following chest pain and shortness of breath is suggestive of myocardial infarction. AST is released from damaged heart muscle cells during a heart attack, indicating cardiac involvement. This enzyme is not specific to liver disease, gallbladder disease, or skeletal muscle injury in this clinical context.

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