Nursing Elites

1. A nurse is assessing a client who is postoperative following a transurethral resection of the prostate (TURP). Which of the following findings should the nurse report to the provider?

• A. Passing small clots in the urine.
• B. Continuous bladder irrigation.
• C. Red-tinged urine with numerous clots.
• D. Urine output of 50 mL/hr.

Correct answer: C

Rationale: The correct answer is C: Red-tinged urine with numerous clots. This finding should be reported because it indicates excessive bleeding following a TURP procedure. Passing small clots in the urine (choice A) is expected post-TURP. Continuous bladder irrigation (choice B) is a standard procedure after TURP to prevent clot retention. Urine output of 50 mL/hr (choice D) is within the expected range postoperatively and does not indicate a complication.

2. A nurse is preparing to administer an intermittent tube feeding to a client who has a gastrostomy tube. Which of the following actions should the nurse take?

• A. Flush the tube with 10 mL of water after feeding
• B. Flush the tube with 30 mL of water before feeding
• C. Place the client in a left lateral position
• D. Place the feeding bag 61 cm (24 in) above the client's abdomen

Correct answer: B

Rationale: The correct action for the nurse to take when preparing to administer an intermittent tube feeding to a client with a gastrostomy tube is to flush the tube with 30 mL of water before feeding. This step helps ensure the patency of the tube by clearing any blockages or residuals. Choice A is incorrect because flushing after feeding would not prevent clogging before the feeding. Choice C is unrelated to tube feeding administration. Choice D is incorrect as the height for the feeding bag is usually recommended to be at or below the level of the stomach to prevent complications like aspiration.

3. A client with diabetes mellitus is being taught by a nurse about managing blood glucose levels. Which of the following client statements indicates an understanding of the teaching?

• A. I will eat a snack if my blood glucose level is below 70 mg/dL.
• B. I will take my insulin if my blood glucose level is above 200 mg/dL.
• C. I will check my blood glucose level once a week.
• D. I will take my insulin only when I feel symptoms of hyperglycemia.

Correct answer: A

Rationale: Choice A is the correct answer because consuming a snack when the blood glucose level is below 70 mg/dL helps prevent hypoglycemia in clients with diabetes mellitus. Choice B is incorrect because taking insulin when blood glucose is high (above 200 mg/dL) helps manage hyperglycemia, not hypoglycemia. Choice C is incorrect as checking blood glucose levels once a week is insufficient for proper diabetes management, which typically requires more frequent monitoring. Choice D is incorrect because waiting for symptoms of hyperglycemia to take insulin can lead to uncontrolled blood glucose levels.

4. A nurse is planning care for a client who is receiving hemodialysis. Which action should the nurse include in the care plan?

• A. Withhold all medications until after dialysis.
• B. Rehydrate with dextrose 5% in water for orthostatic hypotension.
• C. Check the vascular access site for bleeding after dialysis.
• D. Give an antibiotic 30 minutes before dialysis.

Correct answer: C

Rationale: The correct action the nurse should include in the care plan for a client receiving hemodialysis is to check the vascular access site for bleeding after dialysis. This is crucial as it helps in detecting and addressing any bleeding complications that may arise from the dialysis procedure. Choice A is incorrect because medications should not be withheld unless specified by the healthcare provider. Choice B is incorrect as dextrose 5% in water is not typically used for orthostatic hypotension. Choice D is incorrect as giving an antibiotic before dialysis is not a routine practice unless specifically prescribed for a particular reason.

5. Four clients present to the emergency department. The nurse should plan to see which of the following clients first?

• A. A 6-year-old client with a dislocated left shoulder
• B. A 26-year-old client with sickle cell disease and severe joint pain
• C. A 76-year-old client who is confused, febrile, and has foul-smelling urine
• D. A 50-year-old client with slurred speech, disorientation, and headache

Correct answer: D

Rationale: The correct answer is D. A client presenting with symptoms of a stroke, such as slurred speech, disorientation, and headache, requires immediate attention due to the possibility of a neurological emergency. Choices A, B, and C, although concerning, do not present with symptoms as urgent as those of a potential stroke. Dislocated shoulder, sickle cell disease with joint pain, and confusion with febrile illness can be addressed after ensuring the client with stroke-like symptoms receives prompt evaluation and intervention.

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