Nursing Elites

1. A client with a severe prostatic infection that caused a blocked urethra is 3 days post-surgical urinary diversion. The healthcare provider directs the nurse to remove the suprapubic catheter to allow the client to void normally. Which intervention should the nurse implement first?

• A. Cleanse the site around the catheter
• B. Use a 20 ml syringe to deflate balloon
• C. Clamp catheter until the client voids naturally
• D. Empty urine from the urinary drainage bag

Correct answer: B

Rationale: The correct answer is to use a 20 ml syringe to deflate the balloon first when removing a suprapubic catheter. This step is essential to ensure the safe removal of the catheter without causing any harm or discomfort to the client. Deflating the balloon allows for the catheter to be easily removed. Option A, cleansing the site around the catheter, is not the initial step in this process and can be done after catheter removal. Option C, clamping the catheter until the client voids naturally, is incorrect as it can lead to complications like urinary retention. Option D, emptying urine from the urinary drainage bag, is not the first step in removing the suprapubic catheter and does not address the need to deflate the balloon for safe removal.

2. While teaching a young male adult to use an inhaler for his newly diagnosed asthma, the client stares into the distance and appears to be concentrating on something other than the lesson the nurse is presenting. What action should the nurse take?

• A. Remind the client of the importance of using a rescue inhaler for asthma management
• B. Leave the client alone to process his thoughts about the inhaler
• C. Ask the client what he is thinking about at that moment
• D. Pause and inquire if the client has any questions or needs clarification

Correct answer: C

Rationale: In this scenario, the most appropriate action for the nurse to take is to ask the client what he is thinking about at that moment. By doing so, the nurse can understand the client's concerns or distractions, which can then be addressed effectively during the teaching session. Option A is incorrect as it assumes the client is not paying attention due to forgetfulness about the importance of the inhaler, which may not be the case. Option B is incorrect because leaving the client alone without addressing the issue does not facilitate effective learning. Option D, although closer, does not directly address the client's distraction and may not uncover the underlying issue causing the lack of focus.

3. A 12-year-old client who had an appendectomy two days ago is receiving 0.9% normal saline at 50 ml/hour. The client’s urine specific gravity is 1.035. What action should the nurse implement?

• A. Encourage popsicles and fluids of choice
• B. Evaluate postural blood pressure measurements
• C. Obtain a specimen for urinalysis
• D. Assess bowel sounds in all quadrants

Correct answer: A

Rationale: Encouraging fluids helps address dehydration and potentially high urine specific gravity, which is often related to inadequate fluid intake. In this scenario, the client may be at risk of dehydration due to the appendectomy and the high urine specific gravity. Encouraging popsicles and fluids of choice can help increase fluid intake and improve hydration status. The other options are not the priority at this time. Postural blood pressure measurements may be relevant for assessing fluid status but are not the immediate action needed. Obtaining a specimen for urinalysis and assessing bowel sounds are not the priority actions based on the client's condition.

4. A client with leukemia who is receiving myelosuppressive chemotherapy has a platelet count of 25,000/mm3. Which intervention is most important for the nurse to include in this client’s plan of care?

• A. Monitor for signs of activity intolerance
• B. Require visitors to wear respiratory masks
• C. Assess urine and stool for occult blood
• D. Obtain client’s temperature q4 hours

Correct answer: C

Rationale: The correct answer is to assess urine and stool for occult blood. With a low platelet count, there is an increased risk of bleeding. Monitoring for occult blood is essential to detect any signs of internal bleeding. Choices A, B, and D are not the priority interventions in this situation. While monitoring for signs of activity intolerance, requiring visitors to wear respiratory masks, and obtaining the client's temperature are important aspects of care, they are not as critical as assessing for occult blood in a client with a low platelet count.

5. When assessing a client's blood pressure and determining an auscultatory gap, which action should the nurse implement?

• A. Compare the palpated systolic blood pressure with the auscultated pressure
• B. Assess the client for lightheadedness upon standing
• C. Determine if an automated blood pressure reading is consistent with the manual reading
• D. Observe for changes in blood pressure between lying and sitting positions

Correct answer: A

Rationale: When an auscultatory gap is present, comparing the palpated systolic blood pressure with the auscultated pressure is crucial. This helps to accurately measure blood pressure and detect any discrepancies caused by the gap. Assessing for lightheadedness upon standing (choice B) is unrelated to addressing an auscultatory gap. Checking the consistency between automated and manual blood pressure readings (choice C) is important for validation but not specifically for managing an auscultatory gap. Observing blood pressure changes between lying and sitting positions (choice D) is relevant for orthostatic hypotension assessment but not for dealing with an auscultatory gap.

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