Nursing Elites

1. A client with chronic renal failure is receiving peritoneal dialysis. The nurse notes that the client's dialysate output is less than the input and that the client's abdomen is distended. What action should the nurse take first?

• A. Turn the client from side to side
• B. Increase the dwell time of the dialysis
• C. Reposition the client
• D. Milk the catheter

Correct answer: A

Rationale: The correct first action for the nurse to take is turning the client from side to side. This helps to facilitate drainage in peritoneal dialysis. Turning the client can aid in redistributing the dialysate and promoting better drainage. Increasing the dwell time of the dialysis (choice B) may not address the immediate issue of inadequate drainage. Repositioning the client (choice C) might not be as effective as turning the client from side to side. Milking the catheter (choice D) is not recommended as it can lead to complications. In this situation, the priority is to facilitate drainage to address the distended abdomen.

2. The nurse in a community health clinic is interviewing a female client who has three children. The client tells the nurse that she has a new man in her life, with whom she is having a sexual relationship, and that they both smoke cigarettes. Which information is most important for the nurse to provide this client?

• A. Oral contraceptives should be started to prevent an unwanted pregnancy
• B. Children are more prone to upper respiratory infections if exposed to smoke at home
• C. Cigarette smoking increases the risk for peptic ulcers and emphysema
• D. A diaphragm and condom provide effective contraception when used together

Correct answer: D

Rationale: The most important information for the nurse to provide the client in this situation is that using both a diaphragm and a condom together provides effective contraception and also protects against sexually transmitted diseases (STDs). While oral contraceptives can help prevent unwanted pregnancies, using a barrier method like a diaphragm and a condom is crucial in this scenario where the client is engaging in a new sexual relationship. Choice B is important information but is not the top priority in this context. Choice C, although relevant, does not address the immediate concern of contraception and STD prevention. Therefore, the correct answer is D.

3. A nurse is preparing to insert an indwelling urinary catheter in a female client. Which action should the nurse take to maintain sterile technique?

• A. Apply sterile gloves before inserting the catheter
• B. Use sterile gloves to insert the catheter
• C. Clean the urinary meatus with an antiseptic solution
• D. Place the drainage bag above the level of the bladder

Correct answer: B

Rationale: Using sterile gloves to insert the catheter is crucial to maintaining sterile technique. Sterile gloves help prevent the introduction of microorganisms during the insertion process. Applying sterile gloves before cleansing the perineal area (Choice A) is important but not specific to maintaining sterility during catheter insertion. Cleaning the urinary meatus with an antiseptic solution (Choice C) is a step in the catheterization process but does not solely ensure sterile technique. Placing the drainage bag above the level of the bladder (Choice D) is incorrect; the bag should be placed below the level of the bladder to facilitate urine drainage.

4. The nurse is assessing on the first postoperative day following thyroid surgery. Which laboratory value is most important for the nurse to monitor?

• A. Calcium
• B. Sodium
• C. Chloride
• D. Potassium

Correct answer: A

Rationale: Corrected Rationale: Monitoring calcium levels is crucial post-thyroid surgery to detect hypocalcemia, a common complication due to injury or removal of the parathyroid glands. Monitoring sodium, chloride, or potassium levels is not as vital in the immediate post-thyroid surgery period.

5. The nurse observes a client in a wheelchair with a vest restraint in place. What nursing intervention is most important for the nurse to implement?

• A. Assess the need for continued restraint
• B. Check the client for urinary incontinence
• C. Determine skin integrity under the vest
• D. Perform range-of-motion exercises on extremities

Correct answer: A

Rationale: The correct answer is to assess the need for continued restraint. This is the most important nursing intervention as it ensures the client's safety and autonomy. Checking for urinary incontinence (Choice B) may be important but is not the priority in this situation. Determining skin integrity under the vest (Choice C) is essential but not as crucial as assessing the need for continued restraint. Performing range-of-motion exercises (Choice D) is important for client mobility but not the priority when a restraint is in place.

Similar Questions